Health inspection·March 3, 2022

F 0622 Level of Harm - Minimal harm or potential for actual harm 2. There was no contact information for the resident on obtaining assistance (if needed) for obtaining and completing and submitting an appeal form and hearing request. 3. There was no contact information written for resident to contact the State LTC Ombudsman Office, the State Agency for the Developmentally Disabled, or the State Agency for the Mentally Ill. Residents Affected - Some 4. There was no resident/representative signature. The client was self-responsible and should have signed the form. 5. There was no indication of a copy being sent to the State LTC Ombudsman Office and date. During a record review of the nurses' notes in the discharge record of Resident 43, the resident was agreeable to the transfer/discharge to [name of hospital] for evaluation of depression. During a record review on March 3, 2022, at 3:45 PM, of the discharge record for Resident 55, the document titled Notice of Transfer/Discharge Notice, dated December 21, 2021, was incomplete. The following areas were not completed: 1. There were no boxes checked for the reason why the transfer/discharge was necessary. 2. There was no contact information for the resident on obtaining assistance (if needed) for obtaining and completing and submitting an appeal form and hearing request. 3. There was no resident/representative signature. The resident is self-responsible and should have signed the form. 4. There was no indication of a copy being sent to the State LTC Ombudsman Office and date. During a record review of the nurses' notes in the discharge record of Resident 55, the resident was agreeable to the transfer/discharge to [name of psychiatric hospital]. During a concurrent interview and record review with the Director of Nurses (DON), on March 3, 2022, at 4:15 PM, of the Facility's Policy and Procedure (P&P), titled Transfer or Discharge Documentation, revised December 2016, was reviewed. The P&P indicated, .4. When a resident is transferred or discharge from the facility, the following information will be documented in the medical record: a. The basis for the transfer or discharge: (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met (b) this facility's attempt to meet these needs; and (c) the receiving facility's service(s) that are available to meet those needs. b. That an appropriate notice was provided to the resident and/or legal representative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 2 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0622 c. The date and time of the transfer or discharge; Level of Harm - Minimal harm or potential for actual harm d. The new location of the resident; e. The mode of transportation; Residents Affected - Some f. A summary of the resident's overall medical, physical, and mental condition. The DON stated that the Notice of Transfer/Discharge had not been completed for Residents 41, 43 and 55. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 3 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on staff interviews and record reviews, the facility failed to ensure an annual (a comprehensive assessment for a resident that must be completed on an annual basis) Minimum Data Set (MDS- a computerized assessment tool) assessment for one of five residents (Resident 6) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 6. Findings: A review of the facility document titled, admission Record (a document that contains demographic and clinical data), indicated, Resident 6 original admission date to the facility was on June 14, 2017. A review of the MDS assessments for Resident 6 revealed the last annual assessment was completed on January 28, 2021, followed with: a. Quarterly assessment April 30, 2021 b. Quarterly assessment July 23, 2021 c. Quarterly assessment October 23, 2021 No other MDS assessments had been completed since October 23, 2021 During a concurrent interview and record review on March 3, 2022, at 3:00 PM, with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health), the Administrator/MDS nurse confirmed that no other MDS assessments had been completed since October 23, 2021. The Administrator/MDS nurse further stated, she missed completing the annual assessment for Resident 6 and it should have been completed in January 2022. During record review on March 3, 2022, at 3:30 PM, of the facility policy and procedures (P&P) titled Resident Assessment, reviewed and updated on January 28, 2022, indicated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: . (4). Annual Assessment (Comprehensive) - Conducted not less than once every twelve (12) months; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 4 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to ensure a quarterly (a quarterly review for resident that must be completed every 3 months) Minimum Data Set (MDS- a computerized assessment tool) assessment for two of five residents (Resident 3 and Resident 4) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 3 and Resident 4. Residents Affected - Few Findings: A review of the facility document titled, admission Record (a document that contains demographic and clinical data), indicated, Resident 3 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident 3 revealed the last assessment completed was a quarterly assessment completed on September 20, 2021. No other MDS assessments had been completed since September 20, 2021. During a concurrent record review and interview on March 3, 2022, at 2:30 PM, with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health), the Administrator/MDS nurse confirmed that no other MDS assessments had been completed since September 20, 2021, and during interview she stated she missed completing the quarterly assessment for Resident 3 and it should have been completed in December 2021. A review of the facility document titled, admission Record, the admission Record indicated, Resident 4's original admission date to the facility was on February 20, 2019. A review of the MDS assessments for Resident 4 revealed the last assessment completed was a quarterly assessment completed on October 04, 2021. No other MDS assessments had been completed since October 04, 2021. During a concurrent record review and interview on March 3, 2022, at 2:50 PM, with the Administrator/MDS nurse, the Administrator/MDS nurse confirmed that no other Quarterly MDS assessments had been completed since October 04, 2021, and during interview she stated she missed completing the quarterly assessment for Resident 4 and it should have been completed in January 2022. During record review on March 3, 2022, at 3:20 PM, of the facility policy and procedures title Resident Assessment, reviewed and updated on January 28,2022 indicated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments conducted for all residents in the facility: . (2). Quarterly Assessment - Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 5 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed to accurately reflect the resident's status, care and services, in the area of active diagnosis for one of two sampled residents (Resident 505) reviewed. This failure had the potential to cause inaccuracy in identifying resident 505's care and support needs. Residents Affected - Few Findings: A review of the facility document titled, admission Record (a document that contains demographic and clinical data), indicated, Resident 505 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease with early onset (It causes problems with memory, thinking and behavior). During a concurrent interview and record review on March 2, 2022, at 9:35 AM, of Resident 505's electronic clinical records, titled Progress Note-Monthly Medical-new admit, dated January 18, 2022, and interview with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health) confirmed record indicated Assessments .1. Alzheimer's disease with early onset . as one of the Resident 505's diagnosis. During a concurrent interview and record review on March 2, 2022, at 9:45 AM, with the Administrator/MDS nurse, Resident 505's electronic clinical records, titled Progress Note-Monthly Medical-progress notes dated September 01, 2021, were reviewed. The Administrator/MDS nurse confirmed record indicated Assessments .1. Alzheimer's disease with early onset . as one of the Resident 505's diagnosis. During a concurrent interview and record review on March 2, 2022, at 9:55 AM, with the Administrator/MDS nurse, Resident 505's electronic clinical records were reviewed. The Administrator/MDS nurse confirmed the Annual MDS assessment (a comprehensive assessment for a resident that must be completed on an annual basis) dated February 1, 2022, on active diagnosis indicated Alzheimer's disease was not marked as one of the active diagnoses to reflect the status of Resident 505. The Administrator/MDS nurse stated, It should be marked as one of active diagnosis, I missed it and didn't mark it. During record review on March 2, 2022, at 2:20PM, of the facility policy and procedures titled Certifying Accuracy of the Resident Assessment reviewed and updated January 28, 2022, indicated, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 6 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure a Bowel and Bladder care plan was developed to meet and address the needs and goals for one out of five sampled residents (Resident 5). This failure has the potential to prevent Resident 5 from reaching his maximum functional capability and/or prevent any complications that may arise from bowel and bladder incontinence (the lack of voluntary control to hold bowel [stool] and bladder [urine].) Findings: During an interview on March 2, 2022, at 8:24 AM, with Certified Nurse Assistant 1 (CNA 1) identified Resident 5 as one of the residents assigned to her who was incontinent of bowel and bladder. CNA 1 stated that Resident 5 used the call light if he needed to be changed, but the resident was sometimes unaware if he was wet. During a concurrent interview and record review on March 2, 2022, at 8:50 AM, with the Director of Nursing (DON), the DON stated Resident 5 was incontinent of both bowel and bladder according to the Minimum Data Set (MDS-comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems). The same MDS shows that Resident 5 has a Brief Interview for Mental Status score of 00 (BIMS-used to assess cognitive status in elderly patients, wherein a score of 0-7 is severe cognitive impairment, 8-12 is moderate impairment and 13-15 is intact cognitive response). The DON stated, Resident 5 was dependent on staff for toileting needs. The DON stated a care plan should have been developed for Resident 5. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, was reviewed. The P&P indicated, .1. The Interdisciplinary Team (IDT- a group of clinical staff), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The DON stated that the facility did not follow their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 7 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure staff demonstrate the ability to carry out an activity that is within the scope of practice a staff is certified to perform when Certified Nurse Assistant 3 (CNA 3) gave Resident 5 a lunch tray that belonged to another resident. This failure to demonstrate competency had the potential for a diminished quality of service and care for one of five sampled residents (Resident 5). Findings: During an observation on February 28, 2022, at 11:55 AM, CNA 3 was observed distributing lunch meal trays for residents at the dining area. Resident 5 started eating after CNA 3 placed his lunch tray in front of the resident. The diet card (a card that has information on the type of diet that is specific for a resident) on Resident 5's tray indicated the meal he was eating belonged to another resident. During an interview on February 28, 2022, at 12:05 PM, with CNA 3, stated Resident 5 has the same first name as Resident 24, which caused her to distribute the meal tray by mistake. CNA 3 further stated, I should have double-checked the full name that was on the diet card. During a record review on March 3, 2022, at 4:00 PM, the diet order for Resident 5 indicated mechanical soft texture (food that is prepared in a way that makes it easy to eat without having to bite or chew a lot) and Resident 24 was on a regular diet (There is no restriction on type or texture of food.) Resident 5, who had the same first name as Resident 24, was provided with a regular diet tray instead of his mechanical soft diet tray. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, the facility's policy and procedure on the job description, titled, Hillcrest Nursing Home Certified Nurse Aide, revised April 11, 2007, indicated, Essential Duties: .19. Prepare residents for meals. Assist serving food trays or feeds as necessary . The DON stated the CNA 3 did not demonstrate competency when the wrong food tray was served to Resident 5. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 8 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that the menus were followed when: Residents Affected - Some 1. Thirty three out of fifty-four residents were on a regular, No Added Salt (NAS), and low-fat/ low cholesterol diet and received the incorrect dessert for lunch on February 28, 2022. 2. Nine out of fifty- four residents on a large portion diet received four ounces of milk instead of eight ounces of milk for lunch on February 28, 2022. These failures had the potential to decrease the nutritional intake and meal satisfaction for the 54 residents who are immuno-compromised. Findings: 1.During a concurrent observation and interview on February 28, 2022, at 11:32 AM, with a Dietary Aide (DA) in the kitchen during tray line, green Jell-o with whipped cream was served to all the residents. The DA stated that everyone gets the same dessert. During a follow-up interview with the Certified Dietary Manager (CDM), on February 28, 2022, at 3:39 PM, the CDM confirmed that all residents received the diet citrus chiffon delight/whipped gelatin with one tablespoon whipped topping. During a record review of the Winter Menus Week 1 Monday (WM), dated February 28, 2022, the WM indicated that the regular, NAS, and low fat/low cholesterol diets were to receive Citrus Chiffon Delight/ Whipped Gelatin with one tablespoon whipped topping. The residents on a CCHO (carbohydrate-controlled diet for residents with diabetes, a disease that affects how the body uses blood sugar) were to receive DIET Citrus Chiffon Delight/Whipped Gelatin with one tablespoon whipped topping. During a record review of the Recipe: Citrus Chiffon Delight, dated week 1 Monday, indicated May give to the following special diets: 2GM (gram) NA(sodium)/ Low salt, low fat/low cholesterol, mechanical soft (Prepared to require minimal chewing)/ pureed( Blended to pudding consistency)/ dysphagia(difficulty shallowing). During a record review of the facility document titled, Diet Type Report, dated March 1, 2022, thirty-three residents were on regular, NAS, low fat/ low cholesterol, and fortified diet. 2. During tray line observation on February 28, 2022, at 11:32 AM, four ounces of milk were given instead of eight ounces to residents on large portions. During a record review of the Cooks Spreadsheet: Winter Menus Week 1 Monday (WM), dated February 28, 2022, indicated that small and regular portions were to receive four ounces of milk, and large portions were to receive eight ounces of milk. During a record review of the facility document titled, Diet Type Report, dated March 1, 2022, indicated, nine residents were on large portions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 9 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0803 Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's policy titled, Portion Sizes, dated 2018, indicated, Various portion sizes of the food will be available to better meet the needs of the residents .the small and large portion servings will be served as printed on the cook's spreadsheets for every meal. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 10 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 - Many 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 and sanitary food preparation and storage areas were maintained, as well as safe and sanitary practices were maintained in the kitchen when: 1. The ice machine was not kept in a clean and sanitary condition, which put 54 Residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. There were food crumbs and miscellaneous items in an enclosed area on a countertop that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 3. The floor under the deep fryer had food crumbs and trash that had the potential to attract microorganism carrying pests. 4. There was raw chicken that was thawing stored over previously cooked chicken, which had the potential to contaminate the cooked chicken and cause foodborne illness. The facility's failures to ensure a safe and sanitary food preparation and storage area resulted in the increased risk of resident harm related to disease causing microorganisms contaminating the residents' food which could cause food-borne illness to a population of 54 immuno-compromised (having an impaired ability to fight disease) residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Maintenance Supervisor (MS) and the Certified Dietary Manager (CDM), on February 28, 2022, at 8:45 AM, the top/ceiling of the ice machine chute were observed to have black, hard deposits. The back wall of the ice chute and the area where ice is formed within the machine had a black material build-up on the wall that could be wiped off with a paper towel. The Storage Bin Drain Tube, which is a clear tube that drains water from the ice bin, was observed to have a black material build-up within the inside of the tube . When the tube was removed, the noted black material had a slimy in consistency within the inside surface of the tube and this slime that adhered to the tube also extended to where it entered the ice bin. Additionally, the ice bin storage area, which is the area under the ice bin, had noodles noted littered on the bottom. The tray that collected the water that drained from the ice storage bin through the storage bin drain tube, had food crumbs and debris observed. The CDM stated that a company comes out to the facility two (2) times per year to clean the ice machine. The MS stated that he cleans the inside of the ice machine as well as where water drains, twice a month with hot water and a clean cloth . He stated, they rely on the contract company to do the deep cleaning. The last time he cleaned the ice machine was on February 25, 2022, three days prior to the observation and interview. During a follow up interview with the Certified Dietary Manager (CDM) on February 28, 2022, at 9:00 AM, she stated she has been working at the facility since January 2022. She stated that the ice machine cleaning schedule will need to be adjusted for more frequent cleanings and that she thought that the MS was using a sanitizer when cleaning the ice machine. She stated that ice is used for resident beverages and to keep food cold during meal service. She stated that she was not monitoring the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 11 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 cleanliness of the ice machine and was relying on the Maintenance Supervisor to do it. Level of Harm - Minimal harm or potential for actual harm During an interview on February 28, 2022, at 2:30 PM, with the ice machine Service Technician (ST) from [Name of company that services the ice machine], the ST stated that the storage bin drain tube drains onto a tray, water that is from the melting ice drips down this tube and onto the tray, the tray collects the water, and it (the collected water) goes down to the floor drain. It is a small bit of water that drips out, but it gets dirty easily. He recommended that the facility replace all the clear rubber tubing on the ice machine regularly because they are hard to clean, and build-up happens quickly. Residents Affected - Many During a follow-up interview with the MS on March 1, 2022, at 10:56 AM, the MS stated that he was not previously removing the ice bin drain tube to clean it. During a review of the FDA Federal Food Code 2017, it indicated that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During a record review of the Federal FDA 2017 Food Code 4-204.17, indicated The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form . are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferral of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses Recommendations for a regular program of maintenance and disinfection have been published Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. Record Review of the facility document titled, Diet Type Report, dated March 1, 2022, indicated there were 54 residents on PO (by mouth) diet. Record Review of the facility document titled, Ice Machine Cleaning Log, dated year 2022, indicated that the last time that the ice machine was cleaned was on February 25, 2022. Record Review of the facility document titled, [Name of manufacturer's] Instructional Manual, revised April 17, 2019, indicated Yearly: icemaker and dispenser unit/ice storage bin: clean and sanitize per the cleaning and sanitizing instructions provided in this manual. See III.B. Cleaning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 12 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 - Many Sanitizing Instructions. Yearly: Condenser: Inspect. Clean if necessary, by using a brush or vacuum cleaner. More frequent cleaning may be required depending on location. Yearly: water hoses: Inspect the water hoses and clean/replace if necessary. Cleaning and Sanitizing Instructions: The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions . 6. Remove the front insulation panel, then pour 10.4 fl. Oz. (fluid ounces) of [Name of Manufacturer's] Scale away (cleaning product to calcium scale deposits) into the water tank. Replace the front insulation panel . 12. Remove the front insulation panel, then pour 0.6 fl. Oz. (fluid ounces) of an 8.25% sodium hypochlorite solution (chlorine bleach) into the water tank. During a record review of the facility's policy and procedure titled, Ice Machine Cleaning Procedures, dated 2018, indicated, .3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. Add instructions to your policies or use manufacturer procedures to clean and sanitize the machine. During a record review of the facility's policy and procedure titled, Sanitation, dated 2018, indicated, Policy: All equipment shall be maintained as necessary and kept in working order .9. All utensils, counters, shelves, and equipment shall be kept in clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .12. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a concurrent observation and interview with the ST, on February 28, 2022, at 3:49 PM, the ST showed the new storage bin drain tube that he replaced and stated that it's micro bacterial coated. During an interview on March 1, 2022, at 10:56 AM, with the MS and CDM, in front of the ice machine, the MS stated that he will spray the areas where ice is made and where ice touches with a de-scaler and use a scrub brush to clean. He will then use a sanitizer and leave on for 1 minute, then rinse with water. He will remove the tubing and some plastic parts to clean and sanitize. The CDM stated that she will be monitoring cleanliness of the ice machine going forward and will be using the 3-compartment sink to clean the tubing and other plastic parts. During a review of facility's receipt [Name of] Refrigeration Supplies Distributor, dated February 28, 2022, at 3:39 PM, provided by the Administrator (Admin), indicated purchasing of 1 Gallon Ice Machine Cleaner and Ice Machine Sanitizer Concentrate. During a review of facility document titled, In-service on Ice Machine Cleaning and Maintenance, dated February 28, 2022, at 4:15 PM, indicated the Maintenance Supervisor and Certified Dietary Manager completed the competency training on February 28, 2022. 2. During a concurrent observation and interview on February 28, 2022, at 8:19 AM, with the CDM, a sink on the stainless steel counter in the kitchen, that was not being used, which had a stainless-steel cover, contained food crumbs, and miscellaneous items such as: staff lotion, tape, labels, a box alcohol wipes. The CDM stated that it should be kept clean and started discarding the items. During a record review of the facility's policy and procedure titled, Sanitation, dated 2018, indicated, Policy: All equipment shall be maintained as necessary and kept in working order .9. All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 13 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 utensils, counters, shelves, and equipment shall be kept in clean. Level of Harm - Minimal harm or potential for actual harm In a review of the FDA Federal Food Code 2017, 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Residents Affected - Many 3. During a concurrent observation and interview with the CDM, on February 28, 2022, at 8:35 AM, the floor under the deep fryer, had food crumbs and trash. The CDM stated that it should be swept, but was not sure if the fryer could be moved, but stated the staff could sweep under it. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the facility policy's titled Sanitation, dated 2018, indicated .9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over the stove, which will be cleaned by the maintenance staff. 4. During a concurrent observation and interview with the CDM, on February 28, 2022, at 8:25 AM, in the walk-in refrigerator raw chicken was thawing in a metal pan and was directly on top of cooked diced chicken that was thawing in a metal pan. The CDM stated that the raw chicken should be on a different shelf and not directly on top of the cooked chicken. During a record review of the FDA Federal Food Code 2017, it indicated, It is important to separate foods in a ready-to-eat form from raw animal foods during storage, preparation, holding and display to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 14 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 observation, interview, and record review, the facility failed to ensure infection prevention and control measures when: Residents Affected - Few 1. A Certified Nurse Assistant (CNA 1) did not remove gloves and observe hand hygiene after handling soiled linens, and before placing clean new ones on resident's bed. This failure had the potential to spread contaminants present from the soiled linens onto the clean new ones, that could potentially harm one unsampled resident (Resident 19). 2. A Housekeeping Aide 1 (HA 1) placed an undisinfected container of sanitizing wipes on top of one dining table that was disinfected in preparation for the lunch meal. This had the potential to spread pathogens to residents who use the dining table for eating meals. Findings: 1. During a concurrent observation and interview on February 28, 2022, at 8:53 AM, CNA 1 was observed wearing gloves while removing the dirty linens from the bed of Resident 19 and placed the dirty linens inside the soiled linen barrel. CNA 1 then placed a new pillowcase using the same gloves she used to handle the dirty linen and the soiled linen barrel. CNA 1 stated, I should have removed the gloves and washed my hands or used sanitizer before touching the clean linens. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Bed, Making an Unoccupied, revised February 2018, was reviewed. The P&P indicated, .Steps in the Procedure: 1. Wash and dry your hands thoroughly. 2. Wear clean gloves . The same policy indicated, Removing Soiled Linen: .9. Remove gloves and discard into designated container. 10. Wash and dry your hands thoroughly. The DON further stated that hand hygiene should have been done before handling the clean linens to be used for resident's bed. 2. During an observation on February 28, 2022, at 11:20 AM, the HA 1 was observed to disinfect the dining tables located at the dining area. After wiping the tables with bleach germicidal wipes (ready to use cleaner disinfectant), the HA 1 was observed to place the container of the wipes on top of the table he just finished disinfecting. The bottom of the container was observed to be dirty and scratched, with more dirt settled in those scratch marks. The HA 1 stated that the container was not disinfected and should have not been placed on top of the dining table that was just disinfected. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the DON, the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, was reviewed. The P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities . The DON stated while the dining tables were disinfected, the container of the wipes was considered dirty and should have not been placed on top of the table, which caused the dining table to be considered unsanitary again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 15 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that for three out of 31 rooms (Rooms 29, 31 and 32) each resident had the required 80 square feet of space when: 1. For room [ROOM NUMBER], the room measured 152.83 sq ft (square feet) = 76.41 sq ft each. There were two residents (Resident 21 who used a wheelchair) and (Resident 48 who ambulated without assistive device). 2. For room [ROOM NUMBER], the room measured 140 sq ft =70 sq ft each. There were two residents (Resident 34 who used a walker to ambulate- [walk]) and ( Resident 32 who ambulated without assistive device). 3. For room [ROOM NUMBER], the room measured 141.67 sq ft= 70.83 sq ft each. There was one resident (Resident 32 who ambulated without assistive device) in a room with two beds. This failure has the potential to limit the freedom of movement for the residents that occupied the rooms, which could place them at risk for injury. Findings: 1.During a concurrent observation and interview on March 2, 2022, at 9:20 AM, in room [ROOM NUMBER], the following was observed: a. Bed A was located against the wall near the entrance of the room, occupied by Resident 21. Resident 21 was observed sitting on his wheelchair near his bed and stated, he does not need assistance to transfer from the bed to the wheelchair. b. Bed B was located against the wall near the window, occupied by Resident 48. Resident 48 was observed lying in his bed. 2.During an observation on March 2, 2022, at 9:25 AM, in room [ROOM NUMBER], the following was observed: a. Bed A was located against the wall near the entrance door, occupied by Resident 34. Resident 34 was observed lying in her bed and had a walker (Device to help residents walking independently) located next to her bed. b. Bed B was located against the wall near the window, occupied by Resident 32. Resident 32 was observed ambulating without assisted device. 3.During an observation on March 2, 2022, at 9:29 AM, in room [ROOM NUMBER], occupied by Resident 23. Resident 23 was observed ambulating in his room without assistive device. The bed was against the wall by the window. A second bed was against the wall by the door and currently unoccupied. During an observation on March 2, 2022, at 10:00 AM, with the Maintenance Supervisor (MS), the room measurements were completed as followed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 16 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 a. room [ROOM NUMBER], (2 beds): 10'11 x 14' = 152.83 square feet (76.4 square feet per resident) Level of Harm - Potential for minimal harm b. room [ROOM NUMBER], (2 beds): 10' x 14' = 140 square feet (70 square feet per resident) c. room [ROOM NUMBER] ,(2 beds): 10' x 14'2 = 141.67 square feet (70.8 square feet per resident) Residents Affected - Some During a concurrent interview and record review on March 2, 2022, at 3:30 PM, with the Administrator, the facility's letter addressed to California Department of Public Health Applications Unit, dated October 1, 2019, was reviewed. The letter indicated that facility requested room waiver for Rooms 29, 31 and 32. The Administrator stated rooms 29, 31 and 32 were smaller than the required square footage per resident and the facility has not submitted the request for room waiver since October 1, 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 17 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safety practices related to residents smoking for two of two residents (Resident 33 and 38), when Residents 33 and 38 were observed smoking without supervision. Residents Affected - Few This failure has the potential to place Resident 33 and 38 at risk for burns. Findings: During a concurrent observation and interview on February 28, 2022, at 12:36 PM, in the smoking patio, Residents 33 and 38 were observed sitting on a chair, smoking, without staff supervision. Resident 33 stated she was aware she needs to smoke under supervision and the staff will come later to check on us. Resident 38 acknowledged he was smoking without supervision. During an interview on February 28, 2022, at 12:41 PM, with the Director of Nurses (DON), the DON verbalized that staff must supervise residents when they are smoking during the seven smoking breaks scheduled. During an interview on March 2, 2022, at 3:05 PM, with a Certified Nurse Assistant (CNA 2), the CNA 2 verbalized any resident who needs to smoke, shall always be supervised while smoking in the designated area. During an interview on March 3, 2022, at 8:07 AM, with a Certified Nurse Assistant (CNA 1), the CNA 1 verbalized that residents must be supervised during smoking to prevent injuries. During a review of Resident 33's admission Record (clinical record with demographic information), dated March 3, 2022, the admission Record indicated, Resident 33 was admitted into the facility on September 9, 2019, with diagnoses which include bipolar disorder (a mental condition that causes changes in person's mood), anxiety disorder, hypertension (high blood pressure), diabetes (a condition when the body cannot control blood sugar), transient cerebral ischemic attack (brief stroke-like attack), hyperlipidemia (elevated fat in the blood), insomnia. During a review of Resident's 33's Smoking-Safety Screen (screening), dated June 7, 2021, the screening indicated Resident 33 needed to smoke with supervision. During a review of Resident 38's admission Record, dated March 3, 2022, the admission Record indicated, Resident 38 was admitted into the facility on December 27, 2021, with diagnoses which include schizophrenia (mental disorder in which people interpret reality abnormally), psychosis (symptom characterized by delusions or hallucinations), hypothyroidism (low thyroid hormone), convulsions, hyperlipidemia (elevated fat in the blood), nicotine dependence. During a review of Resident's 38's Smoking-Safety Screen, dated December 27, 2021, the screening indicated Resident 38 needed to smoke with supervision. During a concurrent interview and record review on March 3, 2022, at 11:40 AM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Smoking Policy-Residents, revised July 2017, was reviewed. The P&P indicated, .11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 18 of 19 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 555890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Nursing Home 4280 Cypress Drive San Bernardino, CA 92407 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 0926 volunteer worker at all times while smoking. The DON stated the facility did not follow the policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 19 of 19