Health inspection·November 18, 2025

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not implement antibiotic stewardship program according to facility policy.Based on interview and record review, the facility failed to implement its policy and procedure on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for two of six residents reviewed for antibiotic use (Residents 1 and 17) when Residents 1 and 17's Loeb's [a set of clinical guidelines for healthcare providers in long-term care facilities to help them decide when to start antibiotics for residents] Minimum Criteria for Initiating Antibiotic Therapy form were not filled out completely. This failure had the potential to place Residents 1 and 17 at risk for adverse events (undesirable physical side effects or harm resulting from medical treatment), including the development of antibiotic-resistant organisms (bacteria that are no longer killed by the antibiotics designed to destroy them), from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of Resident 1's face sheet, it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cystitis (condition when bladder gets swollen and sore) and paranoid schizophrenia (type of a serious brain illness that makes it hard for a person to tell the difference between what is real and what is not real).During a review on of Resident 1's physician's order, dated November 13, 2025, it indicated, Cephalexin [aka Keflexantibiotic medication used to treat a wide range of bacterial infections in the body] Oral Tablet 500 MG [milligram - unit of measure]. Give 1 tablet by mouth three times a day for r/t [related to] skin tear with redness to (R) [right] hip for 7 Days. A review of Resident 1's Medication Administration Record (MAR) for the month of November 2025, indicated Resident 1 received the prescribed Cephalexin oral tablet from November 13, 2025, through November 17, 2025. During an interview and concurrent record review on November 17, 2025, at 3:45 PM, with the ICP nurse, the ICP nurse reviewed Resident 1's Loeb's [a set of clinical guidelines for healthcare providers in long-term care facilities to help them decide when to start antibiotics for residents] Minimum Criteria for Initiating Antibiotic Therapy form , dated November 10, 2025, which indicated Resident 1 had a suspected Skin and Soft Tissue Infection, and the criteria selected was new or increasing purulent drainage [the medical way of saying a wound is leaking thick, often yellowish, fluid from an infected cut or wound]. The portion of the form indicating whether SSTI was evaluated or whether the criteria were met was left blank. The ICP nurse confirmed the form was incomplete and stated that it should have been completed to indicate whether the initiation of antibiotics was appropriate for Resident 1. 2. During a review of Resident 17's face sheet, it indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia and hyperlipidemia (abnormally high level of fats in the blood),During a review of Resident 17's physician's order, dated November 10, 2025, it indicated, . Keflex Oral Capsule Give 500 mg by mouth three times a day for mole on forearm r/t redness and dry yellow drainage for 10 Days. A review of Resident 17's MAR for the month of November 2025, indicated Resident 1 received the prescribed Keflex oral capsule from November 10, 2025, through November 17, 2025. During an interview and concurrent record review on November 17, 2025, at 3:45 PM, with the ICP nurse, the ICP nurse reviewed Resident 17's Loeb's Minimum Criteria for Initiating Antibiotic Therapy form, dated November 10, 2025, which indicated Resident 17 had a suspected Skin and Soft Tissue Infection, and the criteria selected was new or increasing purulent drainage. The portion of the form indicating whether the information gathered, was evaluated or whether the criteria were met, was left blank. The ICP nurse confirmed the form was incomplete and stated that it should have been completed to indicate whether the initiation of antibiotics was appropriate for Resident 17. During a follow up interview on November 17, 2025, at 4:20 PM, with the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555890 If continuation sheet Page 2 of 4 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 11/18/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ICP nurse, the ICP nurse stated The facility used the Loeb Criteria to help us decide if it's real infection or just symptoms that look like an infection. This process helps ensure that we administer antibiotics only when indicated by the criteria.During a concurrent interview and record review on November 17, 2025, at 4:30 PM, with the Director of Nursing (DON) and the ICP nurse, the DON and ICP nurse reviewed Residents 1 and 17's clinical records and were not able to locate any documentation showing any analysis (looking for trends, spikes, or unusual patterns in the data) to determine if infection was present before antibiotic were used. The ICP nurse stated that he should have been ensuring the completion Loeb Criteria and conducting an analysis to confirm the real infection, to support the appropriate use of antibiotic for Resident 1 and 17. During an interview and concurrent record review on November 17, 2025, at 4:35 PM, with the DON and ICP nurse, the DON and ICP nurse reviewed the facility's policy and procedure (P&P) titled, Antibiotic Stewardship [programs to ensure effective and safe use of antibiotics] - Review and Surveillance [process of continuously and systematically collecting, analyzing, and sharing data] of Antibiotic Use and Outcomes. The P&P indicated, Policy Statement. Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for-improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation. 1. As part of the facility antibiotic stewardship program, all clinical Infections treated with antibiotics will undergo review by the infection preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings . The DON stated the analysis should have been conducted to identify trends in antibiotics use, prevent unnecessary prescriptions, and reduce the spread of drug-resistant infections, but it was not. The DON further stated that the facility's P&P was not followed.During an interview and concurrent record review on November 17, 2025, at 4:45 PM with ICP nurse, the ICP nurse reviewed the facility's P&P titled, Infection Preventionist, dated 2001, which indicated, Policy statement. The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Policy Interpretation and Implementation. 5. The infection preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. The ICP nurse stated he was responsible for the oversight of the facility infection control program. The ICP nurse further stated that the facility's P&P was not followed. Event ID: Facility ID: 555890 If continuation sheet Page 3 of 4 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 11/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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** Three rooms have less than 80 square feet per resident in rooms [ROOM NUMBER].Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for three of 32 resident rooms (rooms [ROOM NUMBER]). This failure had the potential for the residents housed in rooms [ROOM NUMBER] to not have the ability to move about freely if the square footage limited their personal space. Findings:During a concurrent interview and record review, with the Administrator (Admin), on September 29, 2025, at 8:45 AM, the Admin reviewed the Entrance Conference Checklist and stated the facility had room waivers for rooms [ROOM NUMBER], which had less than the required square footage of livable space (less than 80 square feet). During an environmental tour with the Maintenance Supervisor (MS), on November 18, 2025, at 2:00 PM, rooms [ROOM NUMBER] were inspected and the residents' rooms and their measurements of livable space were noted as follows:1. room [ROOM NUMBER] (two beds) measured 151.66 sq. ft = 75.8 sq. ft. per resident2. room [ROOM NUMBER] (two beds) measured: 141.16 sq. ft = 70.6 sq. ft. per resident3. room [ROOM NUMBER] (two beds) measured: 141.67 sq. ft = 70.8 sq. ft. per resident During a follow-up interview with the Admin on November 18, 2025, at 2:15 PM, the Admin confirmed the measurements of the three resident rooms, and stated rooms [ROOM NUMBER] did not meet the 80 sq. ft per resident requirement. The Admin further stated the rooms were not crowded, did not impose any safety hazards to the residents and there were no complaints about space or room issues from the residents occupying these rooms.The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. Event ID: Facility ID: 555890 If continuation sheet Page 4 of 4