Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Manor Sanitarium during CMS and state inspections, most recent first.
RN Staffing Shortage: The facility failed to staff an RN for at least 8 hours a day on multiple days, with PBJ and CASPER reports showing no RN hours on numerous dates across the quarter. The DON said the facility was hiring but could not retain RNs, the full-time RN had left, and the ADM stated there was no staffing waiver and could not say how many days lacked RN coverage. The facility’s Nursing Services policy required sufficient qualified nursing staff at all times to meet residents’ needs safely.
Improper Puree Preparation and Undercooked Beef Patties: A cook prepared pureed foods for a resident without checking the consistency or texture, adding thickener by estimate rather than following measured instructions. In a separate event, beef patties were grilled and served without confirming they reached the manufacturer’s required internal temp of 160°F; the patties were reported at 155°F, and the DS and DON acknowledged the patties were not cooked per guidelines.
Missing behavior monitoring for antipsychotic medication: A resident with schizoaffective disorder was ordered haloperidol, then changed to chlorpromazine, but the order did not include the diagnosis, medical symptoms, or behavior monitoring. The chart also lacked a care plan for the antipsychotic and consent from the responsible party. LN and the DON both confirmed that behavior monitoring, diagnosis, and a care plan were not developed.
A resident on Eliquis for Afib, a resident with dementia due to traumatic brain injury, and a resident with schizoaffective disorder receiving antipsychotic medications did not have documented comprehensive resident-centered care plans for those needs. The IP, LN, and DON all confirmed the missing care plans during record review and interview, and the facility policy stated care plans must be complete, current, realistic, time specific, and appropriate to each resident's needs.
Failure to assess a resident’s respiratory status when the resident reported coughing with phlegm. The resident, who had schizoaffective disorder and also reported smoking and shortness of breath, told staff he had been coughing and said nothing had been done. Nursing documentation noted the cough, but no respiratory assessment or lung sounds were documented, and an LPN stated she had not listened to the resident’s lungs. The DON confirmed the licensed nurses did not complete a thorough lung assessment.
A resident with paranoid schizophrenia and syncope was identified as a smoker, but the medical record did not contain a required smoking assessment. The PM stated residents had to be assessed before going to the smoking area, and the IP and DON both confirmed the assessment was missing from the record despite facility policy requiring it on admission and annually as needed.
Failure to Assess Significant Weight Loss: A resident with paranoid schizophrenia and meal refusals had a care plan for altered nutrition and dehydration risk with a goal weight range of 170 to 185 pounds. After a documented weight gain, the resident experienced a 7.2-lb loss and then a 14.2-lb loss, but there was no documented assessment of the unplanned significant weight loss and no follow-up weight to verify the last weight. CNA reported the resident frequently refused breakfast and lunch, and the DON stated the physician and RD should have been notified when the significant weight loss occurred.
Delayed Initial Physician Visit: The facility failed to ensure a physician/PA completed the initial face-to-face visit for one resident in a timely manner. The resident, who had schizoaffective disorder, was observed walking with a walker and reported coughing that staff had not addressed. The DON stated the initial visit should occur within 72 hours of admission and no later than 7 days, but the PA’s first visit was late, contrary to the facility’s admission procedure.
A resident with Afib received Eliquis 5 mg BID without documented monitoring for anticoagulant side effects. The IP found no documentation of monitoring, and the DON stated licensed nurses should have monitored and documented for abnormal bleeding and bruising. The facility also had no policy addressing anticoagulant side-effect monitoring, and the Eliquis PI notes an increased risk of hemorrhage.
The facility failed to keep the medication storage room free of expired Tuberculin PPD. An LN found an opened vial of Tuberculin PPD that had been in use for more than 30 days, and both the IP and DON stated it should have been discarded because opened PPD is only valid for 30 days. The facility policy also stated expired meds should be removed from the refrigerator.
A facility failed to ensure five resident rooms housed no more than four residents, with each of the identified rooms observed to contain five residents. Surveyors noted no safety hazards during the survey, and there were no resident complaints about space or room issues, with no quality of care or quality of life concerns identified for the residents in those rooms.
Insufficient room space was identified in four 5-bed rooms after surveyors measured each room and found that all four provided less than the required 80 sq. ft. per resident. The ADM later confirmed the measurements for all resident rooms and acknowledged that these rooms did not meet the space requirement; the report also noted the rooms were not crowded and no residents complained about space or room issues.
A resident with severe cognitive impairment and a history of schizophrenia eloped from the facility by exiting through a loose window screen and using discarded equipment in an outdoor storage area to climb over the perimeter fence. Facility staff found that window screens throughout the building were loosely attached, and large objects were stored against the fence, making them accessible for climbing. Maintenance rounds to identify such hazards were not documented, and facility policies for safety and elopement risk assessment were not effectively followed.
The facility failed to staff an RN for at least 8 hours a day on twelve occasions between April and June 2024, as confirmed by the DON and staffing reports. Although LN and CNA staffing was within limits, the absence of an RN potentially compromised resident care and oversight, contrary to the facility's policy on Nursing Services.
A resident with schizophrenia was prescribed eight units of insulin, but two LNs documented administering only six units over three days. Additionally, another LN delayed documenting insulin administration, risking potential double dosing. The facility's policy requires immediate documentation to prevent such errors.
The facility failed to test its water system for Legionella, a bacteria that can cause flu-like symptoms. Interviews revealed that the DON was unaware of any testing, and the MS only checked water temperature, not for bacteria. The ADM acknowledged the lack of testing and mentioned plans to contract the service, although a policy was developed but not approved. This oversight contradicts guidelines requiring facilities to inhibit microbial growth in water systems.
The facility was found to have five resident rooms accommodating five residents each, exceeding the regulatory limit of four residents per room. This situation was observed during a survey, but no safety hazards, complaints, or quality concerns were noted for the residents in these rooms.
The facility did not meet the required minimum of 80 square feet per resident in four rooms, affecting 20 residents. Rooms SWD 1 to SWD 4, each with five residents, measured between 77.1 and 78.9 square feet per resident. Despite this, the rooms were not crowded, posed no safety hazards, and residents did not complain about space issues. The Administrator confirmed the deficiency.
RN Staffing Shortage
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least eight hours a day for 19 days between July 1, 2025, and September 30, 2025. A review of the PBJ Staffing Date Report and CASPER Report 1705 D showed that the facility triggered a No RN hours alert for Quarter 4 of 2025, indicating there were at least four days in the quarter without any RN hours. The report listed multiple dates in July, August, and September 2025 when there were no RN hours recorded. During an interview on 2/12/25, the DON stated that the facility was hiring RNs but had not been able to retain them. The ADM stated the facility did not have a staffing waiver and could not say how many days there was no RN. The DON stated that the full-time RN had left and that the facility was trying to staff the floor, but it was challenging. The facility's undated Nursing Services policy stated that it is the policy of the facility to assure sufficient qualified nursing staff are available at all times to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychological well being.
Improper Puree Preparation and Undercooked Beef Patties
Penalty
Summary
Food was not prepared according to professional standards when a cook prepared pureed foods for a resident without checking the consistency or texture before serving. During observation, the cook blended shredded lettuce, diced tomatoes, diced onions, water, and thickener for one pureed item, then blended baked beans with sauce and thickener for another item. In both instances, the cook poured the blended food into a cup and placed it in a metal container without assessing whether the puree had the proper consistency. The cook stated she did not follow instructions for pureeing food and said she just knew to add about three to four scoops of thickener without measuring or checking the consistency. Food was also not cooked according to the manufacturer's guidelines when beef patties were grilled and served without verifying that they reached the recommended internal temperature. A cook grilled the beef patties on the flat grill and transferred them to a metal container without checking the temperature, repeating this process until all patties were cooked. Later, the patties were reported as having been tempered to 155 degrees Fahrenheit, while the manufacturer's guidelines for the Fresh Beef Patties required cooking to 160 degrees Fahrenheit for a well-done product. The dietary supervisor agreed the patties were safe to serve, and the DON stated the staff did not follow the manufacturer's guidelines.
Missing behavior monitoring for antipsychotic medication
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 40, had specific behavior monitoring in place for the use of an antipsychotic medication. Resident 40 was admitted with a diagnosis of schizoaffective disorder and was observed walking in the hallway with a walker on 2/9/26. The clinical record showed that on 1/25/26 the physician ordered haloperidol 5 mg as needed, and on 2/3/26 the order was changed to chlorpromazine 25 mg every PM. The chlorpromazine order did not include the diagnosis, medical symptoms, or behavior monitoring. The record also showed no documented evidence that a care plan was developed for chlorpromazine and no consent was signed by the responsible party. During interview and record review, LN 1 stated the resident had been receiving haloperidol for aggressive behavior, but there was no behavior monitoring or diagnosis written and that it should have been. The DON stated the resident should have had a care plan, diagnosis, and routine behavior monitoring for the antipsychotic medication, and that these were not developed. The facility policy stated that if a psychotropic medication is ordered, the order should include the dosage, frequency, route, related diagnosis, and medical symptoms, and behavior monitoring shall be initiated.
Failure to Develop Comprehensive Care Plans for Anticoagulant, Dementia, and Antipsychotic Needs
Penalty
Summary
A comprehensive resident-centered care plan was not developed for Resident 2, who was admitted with a diagnosis of unspecified atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. During record review and interview, the IP stated there was no care plan for the anticoagulant, and the IP identified that a care plan should have been in place for the resident's anticoagulant therapy. A care plan was also not documented for Resident 1's dementia diagnosis, despite admission with dementia due to traumatic brain injury. In addition, Resident 40, who was admitted with schizoaffective disorder, had physician orders for haloperidol and later chlorpromazine, but there was no documented evidence of a comprehensive resident-centered care plan for either antipsychotic medication. The LN stated Resident 40 had been prescribed haloperidol for aggressive behavior and that the care plan should have been developed, and the DON stated Resident 40 should have had a care plan for antipsychotic use and Resident 1 should have had a care plan for dementia.
Failure to Assess Respiratory Status for Resident With Cough
Penalty
Summary
The facility failed to assess a resident’s respiratory status when the resident complained of coughing with phlegm. Resident 40 was admitted with schizoaffective disorder and was observed walking in the hallway with a walker on 2/9/26. During that observation, the resident stated, “I’ve been coughing,” and said staff had not done anything about it. The clinical record showed the first nursing documentation of the cough with phlegm on 2/9/26, but no respiratory assessment was documented at that time. The record also showed a physician’s order dated 2/10/26 for guaifenesin dextromethorphan as needed for 10 days. Review of the nursing notes found no documented respiratory assessment in subsequent notes on 2/9/26. During interview, an LN stated the resident had a cough for 2 days, smoked, and had shortness of breath, but had not listened to the resident’s lung sounds. The DON stated the licensed nurses did not perform a thorough lung assessment when the resident complained of a cough, and that such complaints should prompt a thorough lung assessment to identify normal or abnormal lung sounds.
Missing Smoking Assessment for Resident Who Smoked
Penalty
Summary
The facility failed to ensure a smoking assessment was completed for one resident who was identified as a smoker. The resident’s admission record showed diagnoses including paranoid schizophrenia and syncope. During an observation and interview in the smoking area, the Patio Monitor stated that residents who smoke were at risk for burns and that all residents were required to have a smoking assessment before going to the smoking area. The Infection Preventionist reviewed the resident’s medical records and stated there was no smoking assessment documented, even though one was required to ensure patient safety while smoking. The Director of Nursing also stated that a smoking assessment was important to identify smoking-related risk and should have been in the resident’s medical record. The facility policy titled Cigarette Smoking and Distribution of Cigarettes stated that upon admission the resident would be assessed for smoking capacity by the admitting nurse and that smoking assessments would be completed annually and as needed.
Failure to Assess Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for Resident 33, who was admitted with paranoid schizophrenia and had a care plan for altered nutrition less than body requirements related to meal refusals and a potential for dehydration. The care plan identified a goal weight range of 170 to 185 pounds, with interventions to honor food and fluid preferences and refer the resident to the RD as needed. The resident’s recorded weights showed 181.2 pounds on 8/30/25, 180.4 pounds on 8/31/25, 179.8 pounds on 9/1/25, 180.6 pounds on 10/2/25, 183.2 pounds on 11/1/25, and 189.4 pounds on 12/2/25. The resident then lost 7.2 pounds to 182.0 pounds on 1/1/26 and lost another 14.2 pounds to 167.8 pounds on 2/2/26. There was no documented assessment for the unplanned significant weight loss, and there were no further weight recordings to verify that the 2/2/26 weight was correct. Nutritional progress notes documented the 12/12/25 weight gain as not significant, and the RD documented the 1/20/26 loss of 7.2 pounds as not significant. During interview, CNA 1 stated the resident does not like to eat and frequently refuses breakfast and lunch. The DON stated that with a significant weight loss, the physician and RD should have been notified so the resident could be assessed and proper treatment ordered, and stated the resident had a significant weight change that was not assessed in a timely manner.
Delayed Initial Physician Visit
Penalty
Summary
The facility failed to ensure the physician completed the initial face-to-face visit in a timely manner for one resident who was admitted with schizoaffective disorder. The resident was admitted on [DATE], and the record showed that the Physician Assistant completed the History and Physical on 1/9/26. During observation on 2/9/26, the resident was seen walking in the hallway with a walker and stated that he or she had been coughing and that staff had not done anything about it. On 2/12/26, the DON stated that the physician or PA alternates visits with residents and that the initial visit should occur within 72 hours of admission, no later than one week, but the PA’s visit for this resident was late. The DON also stated that the initial visit was important to confirm the resident was adjusting to the environment, review and confirm orders, and complete the assessment. The facility’s undated admission procedure stated that the primary physician’s first visit should be documented within 3 days (72 hours) of admission and no later than 7 days.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that one sampled resident with a diagnosis of unspecified atrial fibrillation was free from unnecessary drugs when the resident received Eliquis 5 mg by mouth twice daily without staff monitoring for signs and symptoms of side effects. During interview and record review, the Infection Preventionist reviewed the physician’s order for Eliquis and stated there was no documentation showing monitoring for negative side effects of the blood thinner, and that such monitoring should have been present. The Director of Nursing stated that the negative side effects of an anticoagulant include abnormal bleeding and bruising, and that licensed nurses should have monitored and documented those side effects for residents receiving a blood thinner. The DON also stated there was no policy on anticoagulants at that time. Review of the facility policy confirmed there was no policy addressing monitoring for anticoagulant side effects. The prescribing information for Eliquis noted an increased risk of hemorrhage and that it can cause serious, potentially fatal bleeding.
Expired Tuberculin PPD Stored in Medication Refrigerator
Penalty
Summary
The facility failed to ensure the medication storage room was free of expired Tuberculin PPD testing solution. During an observation and interview, LN 1 reviewed a vial of Tuberculin PPD 5 units per 0.1 ml that had an open date more than 30 days earlier. LN 1 reviewed the manufacturer’s guidelines and stated the vial had been open for more than 30 days and should have been discarded. The Infection Preventionist stated that once Tuberculin PPD solution is opened, it is valid for 30 days and should not be used past that time. The IP stated using the solution after 30 days could decrease its effectiveness and could have inaccurate results. The DON also stated the vial should have been removed from the refrigerator and disposed of because it was only good for 30 days after opening. The facility policy titled Medication Administration Guidelines stated expired and discontinued medications should be removed from the refrigerator.
Excess Residents in Multiple Shared Rooms
Penalty
Summary
The facility failed to ensure that five of 25 resident rooms—SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]—accommodated no more than four residents. During the initial tour on 2/9/26, surveyors observed that each of these rooms housed five residents. The report states that, during the course of the survey, the rooms did not present any safety hazards, and there were no complaints from the residents in those rooms about space or room issues. The survey team also noted that there were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms.
Insufficient Room Space in Four Multi-Bed Rooms
Penalty
Summary
Four of 25 resident rooms failed to provide the required minimum of 80 square feet per resident. During the initial tour on 2/9/26, surveyors observed that Room SWD 1, a 5-bed room, measured 385.5 sq. ft. total, or 77.1 sq. ft. per resident; Room SWD 2 measured 391.3 sq. ft. total, or 78.2 sq. ft. per resident; Room SWD 3 measured 394.5 sq. ft. total, or 78.9 sq. ft. per resident; and Room SWD 4 measured 390.2 sq. ft. total, or 78 sq. ft. per resident. The report states these four rooms were not crowded and did not impose any safety hazards, and there were no complaints from the residents occupying them. During an interview on 2/12/26, the Administrator confirmed the measurements for all 25 resident rooms and acknowledged that these four rooms did not meet the required 80 square feet per resident.
Failure to Secure Facility Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure the building was secured to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition and a diagnosis of schizophrenia, was able to leave the facility without permission. The incident occurred when a window screen in a resident room was found to be loose, allowing the resident to push it open and exit into an outdoor storage area. Staff observed a shoe print near the window, and it was determined that the resident likely used discarded equipment stored in the outdoor area to climb over the perimeter fence. Further investigation revealed that window screens throughout the facility, including the one involved in the incident, were loosely connected and could be easily pulled forward. The outdoor storage area contained large, discarded objects such as bed frames, wheelchairs, and other equipment, which were stored against the perimeter fence and accessible to residents. The Director of Maintenance reported conducting weekly rounds to check for needed repairs but had no documentation to support these checks. Facility policies required maintaining interior surfaces and equipment in good repair and assessing residents for elopement risk, but these were not effectively implemented in this case.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 hours a day on twelve occasions between April 1 and June 30, 2024. This deficiency was identified through a review of the Payroll-Based Journal (PBJ) Staffing Data Report and CASPER Report 1705, which indicated that no RN hours were recorded for these days. The Director of Nursing (DON) confirmed that on specific dates, including April 11, April 16, April 18, April 22, May 2, May 8, May 16, May 21, May 23, May 27, May 28, May 30, and June 18, 2024, the facility did not have an RN scheduled for at least 8 hours. Although staffing numbers for Licensed Nurses (LN) and Certified Nursing Assistants (CNAs) were within limits, the facility was unable to retain the services of an RN and had no waivers for staffing. The DON acknowledged the importance of having an RN on duty for at least 8 hours a day to oversee patient care and safety, supervise nursing operations, conduct assessments for residents, and provide support during changes in residents' conditions. The facility's policy on Nursing Services emphasizes the need for sufficient qualified nursing staff to meet residents' needs safely and promote their rights, physical, mental, and psychosocial well-being. However, the absence of an RN on the specified days potentially compromised the facility's ability to provide adequate care and oversight for its residents.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate and timely documentation of medication administration for one of the residents, leading to a potential medication error. Resident 22, who was admitted with a diagnosis of schizophrenia, was prescribed eight units of insulin three times a day. However, the Medication Administration Record (MAR) indicated that two Licensed Nurses (LNs) administered only six units of insulin on three consecutive days. During an interview, the Director of Nursing (DON) confirmed that one of the LNs was aware of the physician's order but could not explain the discrepancy in documentation. This inconsistency raised concerns about the potential impact on the resident's blood sugar levels. Additionally, another LN was observed documenting the administration of insulin two hours after it was given, contrary to the facility's policy, which requires immediate documentation. The DON acknowledged that delayed documentation could lead to medication errors, such as double dosing. The facility's policy on medication administration emphasizes the importance of recording each dose in the resident's medical record promptly. These lapses in following established procedures contributed to the deficiency identified by the surveyors.
Failure to Test Water System for Legionella
Penalty
Summary
The facility failed to ensure that its water system was tested for Legionella, a bacteria that can cause flu-like symptoms and thrives in water systems. During an interview, the Director of Nursing (DON) was unaware if the facility was conducting such tests, although she acknowledged the importance of testing to prevent resident infections. The Maintenance Supervisor (MS) also confirmed that he did not test the water for Legionella or any other bacteria, only for temperature, and was unsure if the Administrator (ADM) had arranged for external testing. The Administrator admitted that the facility was not currently testing for Legionella but had plans to contract the service out to a company. The ADM stated that the facility should regularly test and monitor the water to prevent Legionella contamination. Although a Legionella policy and procedure had been developed, it was not yet approved. The report references a Quality Safety Oversight Group memorandum indicating that facilities must have policies to inhibit microbial growth in water systems, which the facility had not yet implemented.
Exceeding Resident Capacity in Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During an initial tour on November 18, 2024, it was observed that five resident rooms (SWD 1, SWD 2, SWD 3, SWD 4, and another room) each accommodated five residents. This arrangement exceeded the allowable number of residents per room, potentially limiting the freedom of movement for the residents and placing them at risk for injury. Despite this, there were no safety hazards, complaints, or quality of care or life concerns identified during the survey for the residents in these rooms.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of livable space per resident in four out of 25 resident rooms. During an initial tour, it was observed that rooms SWD 1, SWD 2, SWD 3, and SWD 4, each housing five residents, measured less than the required space per resident, with measurements ranging from 77.1 to 78.9 square feet per resident. Despite the deficiency, these rooms were not crowded, did not pose any safety hazards, and there were no complaints from the residents about space or room issues. The Administrator confirmed the measurements and acknowledged that these four rooms did not meet the required space standards.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| National City Post Acute | 0.3 mi | ★★★★★ | 25 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Friendship Manor Nursing & Rehab Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Paradise Valley Health Care | 1.6 mi | ★★★★★ | 2 | 0 |
| South Bay Post Acute Care | 2 mi | ★★★★★ | 1 | 0 |
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