Health inspection·May 2, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Responsible Person (RP) for one of three residents (Resident 1) of a change in medical condition when Resident 1 lost weight while in the facility. This failure resulted in Resident 1's RP being uninformed and unaware of Resident 1's significant weight loss. Findings An abbreviated survey was conducted on April 18, 2023, at 12:09 PM, to investigate a complaint related to Quality of Care During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Schizophrenia (interpret reality abnormally), Alzheimer ' s (gradual decline in memory), diabetes (high blood sugar). During a review of the Weight Summary (WS) for Resident 1, dated January 9, 2023, at 2:32 PM, the WS indicated: 1. On January 9, 2023, Resident 1 weighed 86.5 pounds (lb.). 2. On December 20, 2022, Resident 1 weighed 92 pounds which indicated a 5.5 lb. weight loss. (5.5%) 3. On July 4, 2022, Resident 1 weighed 98 pounds which indicated a 11.5 lb. weight loss (11.7%). Resident 1 ' s weight summary indicated Resident 1 had significant weight loss. During a concurrent interview and record review of Resident 1 ' s medical record with Licensed Vocational Nurse 1 (LVN 1), on April 18, 2023, at 2:02 PM, LVN 1 stated, There is nothing in Resident 1 ' s chart to say we notified the responsible person (RP) of the weight loss. We should have notified the RP as soon as the notification of weight loss was received. The facility could not provide documentation to indicate the RP was called regarding Resident 1 ' s continued weight loss. During an interview with the Administrator on April 18, 2023, at 2:35 PM, Administrator stated, When I spoke to the RP, I told her that she wasn ' t notified of the weight loss. The Administrator stated further, I reminded the Director of Nursing (DON) that the RP should have been told that Resident 1 was losing weight. I told the (DON) that we need to notify the family. The RP should have been (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: 555890 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 05/02/2023 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)