Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Nursing Home during CMS and state inspections, most recent first.
Uneven Meal Service at Shared Dining Table: Residents seated together at one dining table were not served at the same time. Two residents received lunch first while three others waited about 10 minutes for their meals, leaving one pair eating while the others sat without food. The DS stated the cart used to transport trays was limited, and later acknowledged that residents at the same table should eat at the same time. The facility’s Meal Service policy stated that all residents at the same table should be served at the same time.
Incomplete antibiotic stewardship review for two residents. Two residents received Keflex for suspected skin and soft tissue infections, but their Loeb Criteria forms were not fully completed because the sections showing whether the SSTI was evaluated and whether the criteria were met were left blank. The DON and ICP nurse could not locate documentation of any analysis to determine whether infection was present before antibiotics were used, and both stated the facility’s antibiotic stewardship and infection prevention policies were not followed.
Insufficient livable space was identified in three two-bed resident rooms after the Admin reviewed room waivers and surveyors measured each room with the MS. The rooms measured 75.8 sq. ft., 70.6 sq. ft., and 70.8 sq. ft. per resident, which was below the 80 sq. ft. per resident requirement. The Admin confirmed the measurements and acknowledged the rooms did not meet the required standard.
The facility failed to store and prepare food safely, with cut watermelon and butter stored at 60°F, above the recommended 41°F. Additionally, cracked spatulas and a dirty microwave shield were found, increasing contamination risks.
The facility did not adhere to the specified menu serving sizes for residents on regular and CCHO diets, serving 3 oz of Salisbury steak instead of the required 4 oz. This discrepancy was observed during meal preparation and confirmed by the DSS and cook. The RD stated that the facility aims to serve the specified menu amounts as a minimum.
The facility failed to ensure consistent documentation of advance directives for two residents. One resident's advance directives indicated DNR, but their EHR showed Full Code, while another resident's directives indicated Full Code, but their EHR showed DNR. The DON confirmed these discrepancies, acknowledging that the facility's policy was not followed.
A facility failed to accurately complete the MDS assessment for a resident, incorrectly coding bed rails as physical restraints. The resident, diagnosed with paranoid schizophrenia and major depressive disorder, was observed without full side rails, and there was no restraint order in her clinical record. The DON and Admin/MDS Nurse confirmed the error, acknowledging the facility's failure to adhere to its policy for accurate assessments.
A CNA failed to follow infection control practices by holding soiled linen against her uniform, risking cross-contamination. The facility's policy requires soiled linens to be handled with minimal agitation and not held close to the body. This breach had the potential to spread infectious diseases to 51 residents and staff.
The facility failed to provide the required 80 square feet per resident in three rooms, with measurements falling short at 76.41, 70, and 70.83 square feet per resident. Observations noted no immediate safety hazards, and residents reported no complaints. A waiver request was submitted to the California Department of Public Health.
Uneven Meal Service at Shared Dining Table
Penalty
Summary
The facility failed to ensure residents seated at the same dining table were served at the same time. During an observation on September 29, 2025, at 12:05 PM in the north dining room, multiple dining tables were pushed together to form one long table with five residents seated together. Two residents were served lunch first, while three other residents remained waiting for their meals. During an interview with the Dietary Supervisor at 12:13 PM, it was stated that the food cart used to transport trays from the kitchen to the dining room was limited in how many trays it could hold, and the remaining residents’ meals would arrive on the next cart. Further observation at 12:15 PM showed the three waiting residents received their food after the first two residents had already been served and were finished eating. The Dietary Supervisor later stated that residents seated at the same table should eat at the same time and that one person should not be eating while the others were waiting. The facility policy titled Meal Service, dated 2023, stated that all residents at the same table should be served at the same time.
Incomplete Antibiotic Stewardship Review for Two Residents
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two residents who received cephalexin for suspected skin and soft tissue infections. For Resident 1, the physician ordered cephalexin 500 mg by mouth three times daily for a skin tear with redness to the right hip for 7 days, and the MAR showed the antibiotic was administered from November 13, 2025, through November 17, 2025. The ICP nurse reviewed Resident 1’s Loeb’s Minimum Criteria for Initiating Antibiotic Therapy form, dated November 10, 2025, which identified a suspected skin and soft tissue infection and selected new or increasing purulent drainage, but the section indicating whether the SSTI was evaluated or whether the criteria were met was left blank. For Resident 17, the physician ordered Keflex 500 mg by mouth three times daily for a mole on the forearm with redness and dry yellow drainage for 10 days, and the MAR showed the antibiotic was administered from November 10, 2025, through November 17, 2025. The ICP nurse reviewed Resident 17’s Loeb’s Minimum Criteria for Initiating Antibiotic Therapy form, dated November 10, 2025, which also identified a suspected skin and soft tissue infection and selected new or increasing purulent drainage, but the portion of the form indicating whether the information gathered was evaluated or whether the criteria were met was left blank. During interviews and record review, the ICP nurse and DON were unable to locate documentation showing any analysis to determine whether infection was present before antibiotics were used for Residents 1 and 17. The ICP nurse stated the facility used the Loeb Criteria to help determine whether symptoms represented a real infection and that this process helps ensure antibiotics are administered only when indicated. The DON and ICP nurse reviewed the facility’s antibiotic stewardship policy and the infection preventionist policy and stated the facility’s policy was not followed.
Insufficient Livable Space in Three Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet of livable space per resident in three of 32 resident rooms. During a concurrent interview and record review with the Administrator, the facility acknowledged having room waivers for the rooms that had less than the required square footage. During an environmental tour with the Maintenance Supervisor, three two-bed rooms were measured and found to be below the required space per resident: one room measured 151.66 sq. ft. total, or 75.8 sq. ft. per resident; another measured 141.16 sq. ft. total, or 70.6 sq. ft. per resident; and a third measured 141.67 sq. ft. total, or 70.8 sq. ft. per resident. In a follow-up interview, the Administrator confirmed the measurements and stated the rooms did not meet the 80 sq. ft. per resident requirement.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several observations in the kitchen. During an inspection, it was found that cut watermelon and butter were stored in a walk-in refrigerator at a temperature of 60 degrees Fahrenheit, which is significantly above the recommended holding temperature of 41 degrees Fahrenheit or lower. The Dietary Services Supervisor (DSS) acknowledged that the refrigerator had stopped functioning earlier that morning, leading to the improper storage temperature. This failure to maintain the correct temperature for perishable food items could potentially lead to foodborne illnesses among the 51 residents who receive food from the kitchen. Additionally, the facility was found to have two cracked and chipped spatulas in the kitchen's utensils drawer, which were not in compliance with the facility's policy and the FDA's 2022 Food Code. These utensils, due to their damaged condition, could harbor foodborne pathogens and transfer harmful chemicals to food. Furthermore, the microwave's anti-splatter shield was observed to have a layer of old and hardened food residue, indicating a lack of proper cleaning and sanitation. These deficiencies in maintaining kitchen equipment and cleanliness standards further increased the risk of food contamination.
Failure to Follow Menu Serving Sizes for Regular and CCHO Diets
Penalty
Summary
The facility failed to adhere to the specified menu serving sizes for residents on a regular and Controlled Carbohydrate diet (CCHO) during lunch on July 22, 2024. The menu indicated that Salisbury steak should be served in portions of 4 oz for residents on a regular diet. However, during an observation of the kitchen's meal preparation and tray line, it was found that the Salisbury steak served weighed only 3 oz, which is 1 oz less than the menu provision. This discrepancy was confirmed by the Dietary Services Supervisor (DSS) and the cook during the observation. The Registered Dietician (RD) confirmed in an interview that the facility's aim is to serve the specified menu amounts as a minimum, not less. The facility's policy and procedure for a regular diet, dated 2023, states that the regular diet is designed to meet the nutritional needs of residents without dietary modifications or restrictions, although individual preferences or intolerances may necessitate the exclusion of certain food items. This failure to follow the menu had the potential to affect the nutritional intake and weight maintenance of 21 residents on a regular and CCHO diet.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that the code status and advance directives were consistent and accurately documented for two residents. Resident 15 was admitted with diagnoses including hypertension, asthma, and schizoaffective disorder. The resident's advance directives, signed on October 6, 2023, indicated a Do Not Resuscitate (DNR) status, but the electronic health record (EHR) showed a Full Code status. During an interview and record review, the Director of Nursing (DON) confirmed that the EHR did not reflect the accurate information of Resident 15's signed advance directives. Similarly, Resident 47, who was admitted with schizoaffective disorder and hypertension, had advance directives signed on October 6, 2023, indicating a Full Code status, while the EHR showed a DNR status. The DON confirmed the inconsistency during a review. The facility's policy on advance directives, revised in September 2022, requires that the plan of care for each resident be consistent with their documented treatment preferences. The DON acknowledged that the policy was not followed, leading to the discrepancies in the residents' records.
Inaccurate MDS Assessment for Physical Restraints
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessments for a resident, specifically under Section P regarding physical restraints. The deficiency was identified during a review of the resident's MDS Quarterly Assessment, which incorrectly indicated the use of bed rails as physical restraints. However, upon observation and interviews, it was confirmed that the resident never had full side rails to prevent her from getting out of bed, and there was no order for restraints in her clinical record. The Director of Nursing (DON) and the Administrator/MDS Nurse acknowledged that the bed rails were mistakenly coded as physical restraints. The resident involved was admitted with diagnoses of paranoid schizophrenia and major depressive disorder. The error in the MDS assessment was discovered during a review of the facility's policy and procedures, which require that assessments accurately reflect the resident's status during the observation period. The facility's failure to follow its policy was confirmed by the DON and the Admin/MDS Nurse, who reviewed the clinical record and the CMS RAI manual, which outlines the necessity for accurate assessments and the proper evaluation of physical restraints.
Infection Control Breach in Linen Handling
Penalty
Summary
The facility failed to maintain proper infection control practices when a Certified Nursing Assistant (CNA 4) did not adhere to the facility's policy and procedure for handling soiled linen. During an observation and interview, CNA 4 was seen holding soiled linen against her body, allowing it to come into contact with her uniform. CNA 4 acknowledged that this practice could lead to cross-contamination. The facility's Infection Preventionist confirmed that dirty linen should be held away from the body to prevent contamination. The facility's policy, titled 'Laundry and Bedding, Soiled,' dated September 2022, specifies that staff should handle soiled textiles and linens with minimal agitation to avoid contaminating air, surfaces, and persons. It also states that contaminated linen and laundry bags or containers should not be held close to the body or squeezed during transport. This failure had the potential to spread infectious diseases to 51 residents and staff in the facility.
Room Size Deficiency in Three Rooms
Penalty
Summary
The facility failed to ensure that three out of thirty-one rooms met the required space of 80 square feet per resident. Specifically, Rooms 29, 31, and 32 were found to be below the required space, with measurements of 76.41, 70, and 70.83 square feet per resident, respectively. These deficiencies were identified during observations conducted on July 25, 2024, where it was noted that residents in these rooms had limited space, potentially restricting their freedom of movement and increasing the risk of injury. During the survey, it was observed that the rooms were not crowded and did not pose any immediate safety hazards to the residents. The residents occupying these rooms were interviewed and reported no complaints regarding the size and space of their rooms. The facility had previously submitted a room waiver request to the California Department of Public Health in January 2024, seeking approval for the rooms in question. The survey team recommended the approval of this waiver request despite the identified deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 762 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shandin Hills Behavior Therapy Center | 0.2 mi | ★★★★★ | 7 | 0 |
| Arrowhead Healthcare Center, Llc | 1.2 mi | ★★★★★ | 11 | 0 |
| Waterman Canyon Post Acute | 3.4 mi | ★★★★★ | 2 | 0 |
| Community Convalescent Center Of San Bernardino | 3.5 mi | ★★★★★ | 0 | 0 |
| Community Hospital Of San Bernardino Dp Snf | 3.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.