Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Nursing Home during CMS and state inspections, most recent first.
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.
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.
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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 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 | — | 0 | 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 | — | 2 | 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.