Health inspection·July 26, 2024

F 0578 During a review of Resident 47's Code Status in her EHR, it indicated Do Not Resuscitate. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON, on July 26, 2024, at 10:16 AM, the DON reviewed Resident 47's Advance Directives and compared it with the Code Status on her EHR. The DON stated the Code Status on Resident 47's EHR did not reflect the accurate information of her signed Advance Directives. Residents Affected - Few During a follow up interview and record review with the DON, on July 26, 2024, at 10:40 AM, the DON reviewed the facility's policy and procedure (P&P) titled, Advance Directives, revised on September 2022, which indicated Policy Statement: Advance directives are honored in accordance with state law and facility policy .If the Resident Has an Advance Directive .2. The director of nursing services (DNS) or designee notifies the attending physician of advance directive (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care .4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive. The DON stated the policy was not followed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 2 of 10 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 07/26/2024 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 observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the physical restraint (any device or method used to limit a resident's movement) under Section P for one of six residents reviewed for MDS (Resident 43). Residents Affected - Few This failure had the potential to cause inaccuracy in identifying Resident 43's care and support needs. Findings: During a review of Resident 43's admission Record (a document that contains demographic and clinical data), it indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a serious mental illness) and major depressive disorder (a mental health condition where a person feels very sad or hopeless for a long time). During a review of Resident 43's MDS Quarterly Assessment (an assessment for a resident that must be completed every 3 months), dated July 1, 2024, under Section P0100 titled Physical Restraints, it indicated Resident 43 had physical restraints of bed rails, that were used in bed daily. During a concurrent interview and observation on July 22, 2024, at 9:46 AM, in Resident 43's room, Resident 43 was sitting on the edge of the bed without the full-size bed side rails (barriers attached to the sides of a bed considered a type of restraint if they are used to prevent a resident from getting out of bed, limit the resident's freedom and mobility). Resident 43 stated that she has never had full side rails to prevent her from getting out of bed. During an interview with the Director of Nursing (DON), on July 26, 2024, at 10:15 AM, the DON stated Resident 43 never had any order for restraints. During a concurrent interview and record review with the Administrator/Minimum Data Set Nurse (Admin/MDS Nurse) and DON, on July 26, 2024, at 10:21 AM, the Admin/MDS Nurse and DON reviewed Resident 43's clinical record which indicated Resident 43 did not have restraint order. Furthermore, the Admin/MDS Nurse and DON stated the bed rails as physical restraint should have not been coded. The Admin/MDS Nurse and DON further stated, it was coded in error. During a concurrent interview and record review with the Admin/MDS Nurse and DON, on July 26, 2024, at 10:40 AM, the Admin/MDS Nurse and DON reviewed the facility policy and procedures titled Certifying Accuracy of the Resident Assessment revised November 2019, indicated The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. The Admin/MDS Nurse and DON stated the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2019, it indicated .The RAI process .require that (1) the assessment accurately reflects the resident's status . When the use of physical restraints is considered, thorough assessment of problems to be addressed by restraint use is necessary to determine reversible causes and contributing factors and to identify alternative methods of treating non-reversible issues . Steps for Assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 3 of 10 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 07/26/2024 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 Level of Harm - Minimal harm or potential for actual harm 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period. 2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations. 3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident's normal function . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 4 of 10 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 07/26/2024 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 Residents Affected - Some 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 menus were followed for 21 residents on a regular and Controlled Carbohydrate diet (CCHO- eating the same amount of carbohydrates every day, to help keep blood sugar, or glucose levels stable) during lunch on July 22, 2024. This failure had the potential for 21 residents on a regular and CCHO diet to have altered nutritional intake and weight loss. Findings: During a review of the Cooks spreadsheet, dated July 22, 2024, the lunch menu indicated the following serving sizes, Salisbury steak: 3 oz (small), 4 oz (regular), 4 oz (large). During an observation of the kitchen's meal preparation and tray line (system of food preparation where hot and/or cold foods are held and served) for lunch on July 22, 2024, at 11:40 AM, with the Dietary Services Supervisor (DSS) and cook, a prepared plate to represent residents on regular and CCHO diet was selected for weight validation. The Cook, along with assistance from the DSS, was asked to remove and weigh the Salisbury steak from the prepared plate using the kitchen food scale. The DSS placed the Salisbury steak on the scale and noted its weight at 3 oz, 1 oz below the menu's provision of 4 oz (for those on a Regular diet). During an interview on July 25, 2024, at 10:39 AM, with the Registered Dietician (RD) and DSS, the RD stated the facility never aims to serve less than what is specified on the menu, but to serve that amount as the minimum. During a review of the facility's policy and procedure (P&P) titled, Regular Diet, dated 2023, the P&P indicated, The regular diet is designed to meet the nutritional needs of residents who do not need dietary modifications or restrictions. Individual preferences or intolerances may necessitate the exclusion of certain food items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 5 of 10 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 07/26/2024 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 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 store and prepare food in accordance with professional standards for food safety when: Residents Affected - Many 1. Cut watermelon and butter were stored in refrigerator at a temperature of 60 degrees Fahrenheit (unit of measurement). 2. Two cracked and chipped spatulas were observed in the kitchen's utensils drawer. 3. The microwave's anti-splatter shield had a layer of food residue. These failures had the potential to cause foodborne illnesses to 51 residents who receive food served by the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS) in the kitchen, on July 22, 2024, at 8:31 AM, a tray with individual servings of cut watermelon and a tray containing several quarter-pound sticks of butter was inside the walk-in refrigerator. The temperature of the walk-in refrigerator was 60 degrees Fahrenheit. The DSS stated their walk-in refrigerator stopped functioning around 7:00 AM (One and half hour ago). The walk-in temperature was found to be 19 degrees Fahrenheit above the proper holding temperature of 41 degrees Fahrenheit (or lower). During an interview with the DSS, on July 25, 2024, at 10:39 AM, the DSS stated the cut watermelon and butter needed to be refrigerated at the proper holding temperature (41 degrees Fahrenheit or lower). The DSS further stated both food items were ultimately disposed of and reordered. During a review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, 1. Refrigerator - 41°F or lower Freezer 0°F or lower to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2°F lower. For example, to hold chicken at 41°F, the air temperature must be 39°F . During a review of the 2022 Food Code by the U.S. FDA (United States Food and Drug Administration), dated 2022, the 2022 Food Code indicated, 3-202.11 Temperature (A) Except as specified in (B) of this section, refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be at a temperature of 5°C (41°F) or below when received. 2. During a tour of kitchen, with the DSS, on July 22, 2024, at 8:54 AM, an observation of the kitchen's utensils drawer was conducted. Two spatulas, which were inside the drawer, were inspected. Pieces of the rubber parts of the spatulas were missing and cracked, while one was also discolored. During an interview with the DSS, on July 25, 2024, at 10:43 AM, the DSS stated broken utensils are to be replaced upon discovery of damage. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated . 11. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 6 of 10 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 07/26/2024 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 During a review of the 2022 Food Code by the United States (U.S.) Food and Drug Administration (FDA), dated 2022, the 2022 Food Code indicated 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. 3. During an observation of the kitchen, with the DSS, on July 22, 2024, at 8:51 AM, the facility's microwave was inspected. The microwave's anti-splatter shield, which was inside the microwave, had a layer of old and hardened brown food residue spanning the inner upmost portion of the shield. During an interview with the DSS, on July 25, 2024, at 10:41 AM, the DSS stated the anti-splatter shield should be cleaned after service prior to its next use. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated . 11. 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 . During a review of the 2022 Food Code by the U.S. FDA, dated 2022, the 2022 Food Code indicated . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 7 of 10 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 07/26/2024 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 maintain infection control practices when a Certified Nursing Assistance (CNA 4) did not follow facility policy and procedure in handling soiled linen. Residents Affected - Few This failure had the potential to cause and spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to 51 residents and staff in the facility. Findings: During a concurrent observation and interview with CNA 4, on July 22, 2024, at 9:21 AM, in Resident 23's room, CNA 4 was holding soiled linen against her body. The soiled linen was in contact with her uniform. CNA 4 stated, I should not be holding it to my uniform; it can cause cross-contamination (transfer of harmful bacteria from one person, object or place to another). During an interview with the Infection Preventionist (IP), on July 23, 2024, at 8:16 AM, the IP stated when holding dirty linen, it must be held away from the body. During a review of the facility's policy and procedure (P&P) titled Laundry and Bedding, Soiled, dated September 2022, it indicated, .5. Staff handled soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Transport. 1 contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 8 of 10 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 07/26/2024 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 three out of thirty-one rooms (Rooms 29, 31 and 32) had the required 80 square feet of space for each resident when: 1. For room [ROOM NUMBER], the room measured 152.83 sq ft (square feet) = 76.41 sq.ft. each. 2. For room [ROOM NUMBER], the room measured 140 sq ft. =70 sq. ft each. 3. For room [ROOM NUMBER], the room measured 141.67 sq ft= 70.83 sq ft each. 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 on July 25, 2024, at 3:20 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance of the room, occupied by Resident 39. Resident 39 was lying on his bed and had a walker (device to help residents walking independently) located next to his bed. b. Bed B was located against the wall near the window, occupied by Resident 48. Resident 48 was walking independently around the room. 2. During an observation on July 25, 2024, at 3:25 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance door, occupied by Resident 43. Resident 43 was lying in her bed and had a walker located next to her bed. b. Bed B was located against the wall near the window, occupied by Resident 40. Resident 40 was lying in her bed and had a wheelchair (mobility device designed to assist people who have difficulty walking or are unable to walk), placed at the end of the bed. 3. During an observation on July 25, 2024, at 3:35 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance door, occupied by Resident 37. Resident 37 was lying in his bed and had a wheelchair, placed at the end of the bed. b. Bed B was located against the wall near the window, occupied by Resident 4. Resident 4 was lying in his bed and had a wheelchair, placed at the end of the bed. During an observation on July 25, 2024, at 3:45 PM, with the Maintenance Supervisor (MS), the room measurements were completed as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 9 of 10 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 07/26/2024 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 with the Administrator (Admin), on July 25, 2024, at 3:55 PM, the Admin reviewed the facility's letter addressed to the California Department of Public Health Applications Unit, dated January 21, 2024, which indicated the facility requested a room waiver for rooms [ROOM NUMBER]. The Admin stated the annual room waiver request was submitted in January 2024. During the survey, the residents occupying Rooms 29, 31 and 32 were interviewed and had no complaints with regards to the size and the space of their rooms. During the survey, observations of rooms Rooms 29, 31 and 32 were conducted. The rooms were not crowded and did not impose any safety hazards to the residents that occupied the rooms. 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: 555890 If continuation sheet Page 10 of 10