Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Heights Healthcare Center during CMS and state inspections, most recent first.
A resident with vascular dementia and substance abuse history, identified as high risk for elopement, was able to leave the facility unnoticed through an unlocked and unalarmed front door. Staff responsible for monitoring the entrance were either not present or unaware of the resident's risk. After being found in the community and hospitalized, the resident was discharged back to the facility by taxi without supervision, and did not enter the building, remaining unattended until located by emergency services. The facility lacked procedures for ensuring safe transportation and adequate supervision for high-risk residents.
A resident with significant ADL needs and incontinence was discharged to a sober living facility that did not provide medical or physical assistance, despite staff and documentation indicating the resident required substantial support. The resident expressed concerns about the discharge, which were not addressed, resulting in an unsafe transfer, a 911 call, hospitalization, and readmission to the facility.
A resident with hemiplegia was discharged without an effective discharge plan, resulting in the resident feeling rushed, unheard, and unprepared. The Social Service Director scheduled the discharge and arranged transport without addressing the resident's concerns or creating a care plan, and staff were not properly informed of the discharge process.
Two residents were discharged without the development or implementation of required discharge care plans. One resident, admitted after surgery, and another with hemiplegia, both lacked documented discharge planning in their records. Staff interviews confirmed that care plans were not created as required by facility policy.
A resident with hypertension developed rashes and later reported a previous unwitnessed fall with a scalp wound. The LPN documented the rashes but did not notify the physician or monitor the skin changes, and failed to thoroughly assess or document the wound before hospital transfer. The fall incident was also not documented, resulting in delayed care and incomplete records.
A facility failed to ensure proper accountability and administration of medications. Controlled Drug Records did not match Medication Administration Records for several residents, leading to discrepancies in narcotic pain medication documentation. A resident did not receive Creon for 13 days due to an insurance issue, and another resident was given metformin without food, against prescriber's orders.
A resident with pancreatic insufficiency did not receive Creon for 13 days after re-admission to a facility, despite having physician orders. The medication was delivered but not administered, leading to symptoms like oily stool and abdominal pain. Facility records showed multiple entries of the medication being unavailable or incorrectly marked as given, and the resident's discomfort was documented.
The facility failed to honor the food preferences of five residents during a lunch service. A resident who dislikes fish was initially served it, another who prefers double portions received a single portion, and a vegetarian was served meat due to a shortage of veggie patties. Additionally, a resident who dislikes tomato soup was served it, and another who dislikes cranberries received a cranberry dessert. The facility's policy requires adherence to food preferences, which was not initially followed.
A facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their medical history. One resident's MARs incorrectly showed doses of Creon administered when the medication was unavailable, while another resident's Dialysis Communication Forms inaccurately documented a graft instead of a Perma-cath. Interviews revealed a lack of training and discrepancies in documentation, highlighting a failure to adhere to the facility's standards for accurate record-keeping.
A resident with dementia was inaccurately coded as a non-smoker on their annual MDS, despite being observed smoking and identified as a smoker in the facility's Smoking Safety Evaluation. The MDSN admitted the oversight, and the DON emphasized the importance of accurate MDS assessments for CMS reporting.
A resident with severe cognitive impairment was observed smoking without the required protective apron, despite facility protocols mandating its use for safety. The smoking monitor, aware of the risk, did not enforce the apron use after the resident expressed displeasure. Facility records and staff interviews confirmed the necessity of the apron to prevent potential accidents.
The facility failed to follow the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. White rice was served instead of brown rice, and two residents did not receive the required fortified additives in their meals until it was pointed out. The facility's policies for menu changes and meal fortification were not properly followed.
A resident who primarily speaks Spanish experienced miscommunication and anxiety due to the facility's failure to develop a comprehensive care plan addressing language barriers. The facility did not utilize available translation resources, leading to confusion during care. The DON acknowledged the oversight, as the resident's admission data indicated the need for a communication care plan, which was not created.
A resident reported $2,400 missing from his room after selling his truck, but the facility failed to conduct a thorough investigation. The Administrator admitted to not interviewing all relevant staff or documenting the investigation properly. The resident's grievance was not resolved in writing, violating the facility's policy on handling grievances.
A resident with a history of falls, dementia, and polyneuropathy experienced unwitnessed falls on two occasions. The facility failed to update the care plan with new interventions, despite the Interdisciplinary Team not determining a specific root cause. The Director of Nursing acknowledged the oversight, which placed the resident at risk for continued falls.
The facility did not inform residents or their representatives about updates to care plans and physician's orders after water tested positive for Legionella bacteria. Despite having care plans for monitoring signs of Legionnaires' disease, residents with chronic conditions were not notified, violating the facility's policy on resident rights.
Failure to Prevent Elopement and Ensure Safe Return of High-Risk Resident
Penalty
Summary
A facility failed to provide adequate supervision and ensure a safe environment for a resident assessed as high risk for elopement. The resident, who had vascular dementia and a history of psychoactive substance abuse, was identified on admission as ambulatory with exit-seeking behaviors and a desire to leave the facility. Despite being listed as high risk in the facility's elopement binder, the resident was able to leave the facility unnoticed through an unlocked and unalarmed front door, which was routinely left open during the day. Staff responsible for monitoring the entrance, including receptionists and nursing staff, were either not present or unaware of the resident's elopement risk at the time of the incident. The resident was later found in the community and required emergency department evaluation after testing positive for methamphetamine. Further deficiencies were observed in the facility's handling of the resident's return from the hospital. The facility did not confirm the type of transportation arranged for the resident, who was discharged by taxicab without supervision, despite the known elopement risk. Staff did not meet the resident upon arrival, and the resident did not enter the facility, remaining unattended in the community until located by emergency services. The facility lacked a policy or procedure for ensuring safe or supervised transportation for high-risk residents returning from the hospital, and staff interviews revealed a lack of clarity and responsibility regarding this process. Observations and interviews also revealed that the facility's front entrance was frequently left unlocked and unalarmed, with the expectation that the receptionist would monitor the entrance. However, the reception desk was sometimes left unattended, and staff acknowledged this presented a safety issue for residents at risk for elopement. Additionally, some staff were unaware of which residents were classified as high risk for elopement, and the resident in question was not wearing a wander guard bracelet prior to the incident. The facility's elopement policy did not address verification of safe or supervised transportation for returning residents at risk for elopement.
Failure to Ensure Safe and Coordinated Discharge for Dependent Resident
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge for a resident who required substantial assistance with activities of daily living (ADLs), including dressing, transferring, bathing, toileting, and was frequently incontinent of urine and bowel. Despite the resident's documented need for significant support and his own expressed concerns about the appropriateness of the discharge destination, facility staff informed him that he needed to leave due to insurance issues and being considered 'high functioning.' The resident was discharged to a sober living facility that did not provide any medical or physical assistance and required residents to be independent in all ADLs. Interviews with certified nursing assistants confirmed that the resident was always incontinent, never used the bathroom independently, and required help with showering, dressing, and transfers. The social services director acknowledged that the resident had voiced concerns about the lack of support at the sober living facility, but the case manager assured him that caregivers would be available, which was not accurate. Upon arrival at the sober living facility, staff there were surprised by the resident's care needs, as they had been informed he was independent and ambulatory. The facility representative stated they would not have accepted the resident had they known the extent of his needs. The resident was unable to receive necessary care at the sober living facility, leading to a 911 call and transfer to the hospital, after which he was readmitted to the skilled nursing facility. The facility's own policy required the care planning team to assess the availability and capability of caregivers at the discharge location and to address factors that could make the resident vulnerable to preventable readmission, which was not followed in this case.
Failure to Develop and Communicate Effective Discharge Plan
Penalty
Summary
The facility failed to develop an effective discharge plan that ensured a resident's discharge goals were identified and addressed. The resident, who had hemiplegia, was informed by the Social Service Director (SSD) only one day prior to discharge that he would be leaving the facility. Despite expressing concerns regarding finances and the need for a wheelchair, the resident felt that the SSD did not listen or address these issues. The resident was also unaware of his discharge destination and had to contact family members himself to inform them of the impending discharge. Staff interviews revealed a lack of communication and preparation for the discharge. The Certified Nursing Assistant (CNA) was not informed of the discharge by the licensed nurse, learning about it from another resident instead, and had to hurriedly gather the resident's belongings. The licensed nurse was also unaware of the discharge until reviewing the medical record, which showed that the SSD had scheduled the discharge and arranged transport without a care plan or physician's order. The SSD acknowledged that a discharge care plan should have been created and that the resident's preferences were not considered. The facility's policy requires advance preparation and a post-discharge plan, which was not followed in this case.
Failure to Develop and Implement Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement discharge care plans for two of three sampled residents. For the first resident, who was admitted following surgery, there was no evidence in the medical record that a discharge care plan was created prior to their discharge. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that a discharge care plan should have been completed at admission, but was not present for this resident. The second resident, admitted with hemiplegia, was observed on the day of discharge without knowledge of their discharge destination. A review of this resident's medical record also revealed the absence of a discharge care plan. The SSD confirmed that a discharge care plan was not developed for this resident, despite facility policy requiring a baseline care plan within 48 hours of admission and a comprehensive, person-centered care plan to be implemented for each resident.
Failure to Notify Physician and Document Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition and to monitor skin changes for a resident who developed rashes on the head and above the forehead. Documentation showed that a licensed nurse noted the rashes but did not provide evidence of physician notification or ongoing monitoring. Additionally, the same resident reported a previous unwitnessed fall and a wound on the scalp, but there was no detailed assessment or documentation of the wound's appearance or size prior to the resident's transfer to the hospital. The medical record also lacked documentation of the fall incident itself. An interview with the Assistant Director of Nursing confirmed that changes in condition, such as falls, rashes, or wounds, should be reported to physicians and thoroughly documented, including detailed wound observations. The facility's policy requires prompt physician notification and comprehensive documentation of observations prior to contacting the provider. The lack of documentation and physician notification resulted in delayed care and incomplete medical records for the resident.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications and the accurate and timely administration of resident medications. For four residents, the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR), leading to discrepancies in the documentation of narcotic pain medications. Specifically, doses of oxycodone and hydrocodone with acetaminophen were signed out but not documented as administered in the MAR, raising concerns about potential duplicate administration and lack of proof that residents received their medications. Additionally, the facility did not provide a resident with Creon, a medication for pancreatic insufficiency, for 13 days due to an insurance coverage issue. The resident was discharged from the hospital with a new prescription for Creon, but the facility failed to follow up with the pharmacy in a timely manner to resolve the insurance issue and obtain the medication. The resident did not receive the medication until the facility signed an authorization form to pay for the medication, resulting in a delay in the management of the resident's pancreatic insufficiency. Furthermore, a resident was administered metformin, a diabetes medication, without food, contrary to the prescriber's orders. The medication was given before lunch, which had not yet started, potentially leading to gastrointestinal side effects. The facility's policy requires medications to be administered in accordance with orders, including any specified time frames, but this was not adhered to in this instance.
Failure to Administer Creon Leads to Resident's Digestive Symptoms
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they did not administer Creon, a medication for pancreatic insufficiency, to a resident for 13 days. The resident had been discharged from the hospital with a new prescription for Creon to be taken with meals and snacks due to pancreatic insufficiency. Despite having physician orders for the medication, the resident did not receive it upon re-admission to the facility, leading to digestive symptoms such as oily stool, abdominal pain, and nausea. Interviews and record reviews revealed that the pharmacy delivered the medication to the facility, but it was not administered to the resident. The Consultant Pharmacist and other pharmacists confirmed the delivery and the importance of the medication for the resident's condition. The Director of Nursing and Medical Director were informed of the missed doses, and the facility's records showed multiple entries indicating the medication was not available or incorrectly marked as administered. The resident experienced significant discomfort and symptoms due to the lack of medication, including abdominal pain and oily stools. The facility's policies on medication administration and error handling were not followed, as the medication was not given in accordance with the physician's orders, and the physician was not promptly informed of the missed doses. The resident's medical records and care plans documented the missed doses and the subsequent notification to the medical staff, highlighting the facility's failure to administer the medication as prescribed.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of five residents during a lunch service, as observed on 1/8/25. Resident 1, who dislikes fish, was initially served fish before it was replaced with a hamburger patty. Resident 11, who prefers double portions of meat, fish, or eggs, was served a single portion of fish, which was later corrected. Resident 75, who dislikes tomato soup, was served it before it was removed. Resident 151, a vegetarian, was served a meat patty instead of a veggie patty due to a shortage, which was later rectified. Resident 49, who dislikes cranberries, was served a cranberry dessert, which was replaced with vanilla ice cream. Interviews with the residents revealed that some were losing weight and had specific dietary preferences that were not initially honored. The Food Nutrition Service Manager and the Registered Dietician both stated that resident food preferences should be respected, as it is a resident's right. The facility's policy mandates that food preferences be adhered to within reason, with initial screenings to be completed within seven days of admission. The failure to adhere to these preferences was identified during a lunch tray line observation and subsequent interviews with the residents and staff.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure accurate and concise medical records for two residents, leading to potential inaccuracies in their medical history and response to care. For Resident 30, the Medication Administration Records (MARs) incorrectly indicated that nine doses of Creon, a medication for pancreatic insufficiency, were administered between December 25, 2024, and January 9, 2025, when the medication was not available and had not been administered. Interviews with Resident 30 and the Director of Nursing (DON) confirmed that the first dose was given on January 7, 2025, contradicting the MAR entries. A physical count of the Creon capsules further verified the discrepancy, as the number of capsules remaining did not align with the documented administrations. For Resident 71, the facility's Dialysis Communication Forms inaccurately documented the presence of a graft instead of a Perma-cath, which is the actual dialysis access site for the resident. This error was found in five out of sixteen forms reviewed, spanning from December 3, 2024, to January 7, 2025. Interviews with the Director of Staff Development (DSD) and Licensed Nurses (LN) revealed a lack of in-service training regarding dialysis access sites, contributing to the documentation errors. The DON acknowledged the importance of accurate post-dialysis assessments to identify potential complications and confirmed the inaccuracies in the documentation. The facility's policies on charting and documentation emphasize the need for complete and accurate records to facilitate communication among the interdisciplinary team. However, the discrepancies in the MARs for Resident 30 and the Dialysis Communication Forms for Resident 71 highlight a failure to adhere to these standards, potentially leading to confusion and miscommunication regarding the residents' conditions and treatments.
Inaccurate MDS Coding of Resident's Smoking Status
Penalty
Summary
The facility failed to accurately assess and code a resident's smoking status on their annual Minimum Data Set (MDS), a clinical assessment tool required by the Centers for Medicare and Medicaid Services (CMS). The resident, who was admitted with a diagnosis of dementia, was observed smoking on multiple occasions, both with and without a protective smoking apron, under the supervision of a smoking monitor. Despite these observations and a facility Smoking Safety Evaluation identifying the resident as a smoker, the MDS inaccurately indicated that the resident was not a user of tobacco products. The Minimum Data Set Nurse (MDSN) acknowledged the error during an interview, stating that the resident's smoking status was missed during the assessment process. The Director of Nursing (DON) expressed an expectation for MDS assessments to be accurate to ensure CMS has a correct understanding of the resident's current health status. The inaccurate coding of the resident's smoking status on the MDS had the potential to misinform CMS about the resident's health condition.
Failure to Ensure Resident Safety During Smoking
Penalty
Summary
The facility failed to ensure the safety of Resident 50, who was identified as requiring a smoking apron while smoking, to prevent potential accidents. Resident 50, diagnosed with dementia and having severe impaired cognition, was observed smoking without the required protective apron on one occasion, despite being supervised by a smoking monitor. The smoking monitor admitted to not enforcing the use of the apron after Resident 50 expressed displeasure, even though the monitor was aware of the potential risk of the resident's clothing catching fire. The facility's records, including the Smoking Safety Evaluation and care plan, clearly indicated that Resident 50 was a smoker who required a smoking apron for safety. Interviews with the smoking monitor, a licensed nurse, and the Director of Nursing confirmed that the apron was a necessary safety measure. The facility's policy mandated that residents identified as needing assistance for smoking safety should not smoke unsupervised, and the apron was part of the required supervision. Despite these protocols, the failure to ensure Resident 50 wore the apron while smoking constituted a deficiency in resident safety measures.
Failure to Follow Menu and Provide Fortified Meals
Penalty
Summary
The facility failed to adhere to the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. During a lunch tray line observation, it was noted that white rice was served instead of the brown rice listed on the menu. The cook admitted to not closely reviewing the menu and preparing white rice without notifying the Registered Dietician, who confirmed that brown rice is more nutritious. The facility's policy requires that any menu changes be approved by the Registered Dietician or the Food Nutrition Service Director, which was not followed in this instance. Additionally, two residents did not receive the fortified meals as prescribed. Resident 32, diagnosed with moderate protein-calorie malnutrition, was served a meal without the required fortified additive, which was only added after being pointed out. Similarly, Resident 86, with a diagnosis of a displaced fracture, was served a meal lacking the fortified additive until it was noticed and corrected. The Food Nutrition Service Manager and Registered Dietician both emphasized the importance of fortified foods for residents experiencing weight loss, as they provide necessary additional calories. The facility's policy outlines the process for identifying residents needing fortification and the addition of calories or protein to their meals, which was not properly executed in these cases.
Failure to Develop Comprehensive Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who primarily communicates in Spanish, which had the potential to cause psychosocial harm. During an interview, the resident expressed difficulty in communicating with a CNA who did not understand Spanish, leading to confusion and anxiety during care. The facility's procedure for language barriers was not followed, as the language line or other translation resources were not utilized, resulting in miscommunication about the resident's needs. The Director of Nursing acknowledged that the resident's admission Minimum Data Set indicated a need for a communication care plan, which was not created. This oversight was attributed to a missed step in the care planning process. The facility's policy required care plan interventions to be based on a comprehensive assessment, but in this case, the necessary communication care plan was absent, impacting the quality of care provided to the resident.
Inadequate Investigation of Missing Money Grievance
Penalty
Summary
The facility failed to thoroughly investigate an allegation of missing money for a resident, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The resident, who had a cognitive score indicating intact cognition, reported that $2,400 was missing from his room after he had hidden it in a shoe. The resident had received the money from selling his truck and had asked the Social Service Director for assistance in opening a savings account, which was not provided. The resident reported the missing money to a charge nurse and filed a grievance with the Social Service Director, but there was limited documentation of the investigation. The facility's investigation into the missing money was inadequate. The Administrator admitted to not conducting a thorough investigation, as only two staff members were interviewed, and no written statements were taken. The facility did not contact the family friend who sold the truck to verify the transaction, and there was no documented evidence of a written resolution to the grievance. The Business Office Manager stated that residents were provided with instructions about safeguarding valuables, but the resident was not informed of this policy. Interviews with staff revealed inconsistencies in the handling of the grievance. The charge nurse who received the initial report did not document the incident, and the Manager of the Day was unsure if the incident was reportable. The Administrator acknowledged that the investigation could have been more thorough and that documentation should have been attached to the grievance. The facility's policy required a written response to grievances, which was not provided in this case.
Failure to Update Care Plan for Resident with Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was reviewed for falls, which resulted in a potential risk for further falls and injuries. The resident, who was admitted with diagnoses including repeated falls, dementia, and polyneuropathy, experienced unwitnessed falls on two separate occasions. Despite these incidents, the care plan was not updated with new interventions to prevent future falls. The Assistant Director of Nursing (ADON) acknowledged that the root cause of the falls was attributed to dementia, but no additional interventions were implemented beyond staff in-service training on falls. The Director of Nursing (DON) confirmed that the Interdisciplinary Team (IDT) did not determine a specific root cause for the falls and failed to update the care plan with patient-centered interventions. The facility's policy on falls, which requires continuous evaluation and reconsideration of interventions if falls persist, was not adhered to. This oversight placed the resident at risk for continued falls, as the care plan did not address new strategies to mitigate the risk of falling.
Failure to Inform Residents of Legionella Exposure
Penalty
Summary
The facility failed to notify residents and their representatives about updates to their care plans and physician's orders following exposure to Legionella bacteria. This deficiency was identified during an unannounced onsite visit, where it was discovered that the facility's water tested positive for Legionella bacteria. Despite this, the Assistant Director of Nursing (ADON) confirmed that residents and their families had not been informed of the exposure. The Director of Nursing (DON) also stated that residents did not need to be informed of physician's orders unless there was a change in their condition, although they should be involved in their care planning. Three residents were specifically mentioned in the report. Two of them were readmitted with chronic obstructive pulmonary disease, and one was admitted with chronic congestive heart failure. Physician's orders were obtained for all residents to be monitored for signs and symptoms of Legionnaires' disease, and care plans were developed accordingly. However, the residents and their representatives were not made aware of these updates, which is a violation of the facility's policy on resident rights, which mandates resident and family participation in care planning and notification of health conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Hills Post Acute Care | 0.3 mi | ★★★★★ | 0 | 0 |
| Balboa Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 7 | 0 |
| St. Pauls Health Care Center | 1.3 mi | ★★★★★ | 9 | 0 |
| The Pavilion At Ocean Point | 2.9 mi | ★★★★★ | 24 | 0 |
| The Shores Post-acute | 3.3 mi | ★★★★★ | 6 | 0 |
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