Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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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 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.