Hillcrest Heights Healthcare Center

F-F842)

- Six of 26 entries marked as administered.

A review of Resident 30's Nutrition Documentation for meal intake, dated 12/26/24 to 1/8/25, indicated Resident 30 ate three meals every day.

A review of Resident 30's December 2024 MAR for Creon one capsule as needed with snacks, dated 12/24/24 to 12/31/24, indicated zero administration entries.

A review of Resident 30's January 2025 MAR for Creon one capsule as needed with snacks, dated 1/1/25 to 1/8/25, indicated zero administration entries.

A review of Resident 30's Nutrition Documentation for HS (bedtime) Snacks, dated 12/24/24 to 1/6/25, indicated Resident 30 ate a bedtime snack on 11 of 14 days.

A review of Resident 30's care plans, dated 1/5/25, indicated .Resident missed 3 or more doses of medication Creon . and .Notify MD/NP of missed doses of medication .

A review of the facility's policy and procedures titled Administering Medications, dated December 2012, indicated:

.Medication must be administered in accordance with the orders, including any required time frame . and

.Medication must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

A review of the facility's policy and procedures titled Adverse Consequences and Medication Errors, dated April 2014, indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders . and Level of Harm - Minimal harm or potential for actual harm .Examples of medication errors include .Omission - a drug is ordered but not administered .

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39220

Residents Affected - Few Based on observation, interview, and record review, the facility failed to follow the posted menu. In addition, two of 88 residents (Resident 32 and 86) did not receive a fortified (foods with nutrients added to them), meal as ordered, when reviewed for nutritional needs.

This failure had the potential for residents' nutritional needs to not be met.

Findings:

A lunch tray line observation was conducted in the kitchen on 1/8/25 at 12:10 P.M. The lunch meal consisted of oven crisp fish, sweet potato fries or brown rice, seasoned carrots, wheat roll, and cranberry crunch bar for dessert.

1. An observation was conducted on 1/8/25 at 1:23 P.M., during lunch tray line service in the kitchen. Some lunch trays contained white rice, in lieu of the sweet potato fries. The posted daily menu listed brown rice or sweet potato fries as being served with the fish. The cook was questioned about the white rice and went to view the posted menu. The cook stated It does indeed say brown rice. The cook stated, I did not look at it closely and made white rice instead. The cook stated the Registered Dietician was unaware white rice was made, instead of brown rice.

An interview was conducted with the Food Nutrition Service (FNS) manager on 1/8/25 at 1:50 P.M. The FNS stated when white rice was served instead of brown rice the cook was not following the menu.

An interview was conducted with the Registered Dietician (RD) on 1/8/25 at 4:05 P.M. The RD stated brown rice contains more fiber and nutrients then white rice. The RD stated she should have been notified the posted menu was not being followed, to ensure residents were getting all their nutrients.

According to the facility's policy, titled Meal Planning, dated 2023, .3. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet .Only the Facility Registered Dietician or FNS Director can make permanent changes. The FNS Director is to receive the Facility Registered Dietician's approval for any permanent changes .Menu changes should also be noted on the menus on the consumers board and any other menus which may be posted .

2a. Resident 32 was admitted to the facility on [DATE REDACTED], with diagnoses which include moderate protein-calorie malnutrition per the facility's Admission Record.

An observation of the lunch tray line was conducted on 1/8/25 at 12:20 P.M. Resident 32's meal was compared to the plate prepared. The meal ticket listed fortified ground consistency with double meat, fish, eggs. The plate contained fish, carrots, and white rice. No fortified additive was noted. The cook was asked what fortified additive was being used. The cook stated, melted butter on the vegetables and rice, if indicated

The cook stated, I forgot to add the melted butter to Resident 32's meal. The plate was returned to the cook prior to putting on the food cart, and additional butter was added.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 2b. Resident 86 was admitted to the facility on [DATE REDACTED], with diagnoses which included displaced fracture of

the right lower leg, per the facility's Admission Record Level of Harm - Minimal harm or potential for actual harm An observation of Resident 86's lunch tray was compared to his meal ticket on 1/8/25 at 1:37 P.M., during tray line. Resident 69's meal ticket read, Fortified regular consistency. The plate contained fish, carrots, Residents Affected - Few sweet potato fries, and dessert. No additional butter was added to the carrots. The plate was covered and getting ready to place on the food cart for delivery. The meal ticket was pointed out to staff that no fortified additive was present. The cook added butter to the carrots without commenting.

An interview was conducted with the Food Nutrition Service Manager (FNS) on 1/8/25 at 1:50 P.M. The FNS stated fortified foods were required for residents experiencing weight loss. The FNS stated if the fortified additive were not added, they were not meeting the resident's nutritional needs.

An interview was conducted with the Registered Dietitian (RD) on 1/8/24 at 4: 05 P.M. The RD stated fortified additives were important to provide residents experiencing weight loss with additional calories. The RD stated if the residents were not getting their fortified additives, it could be contributing to their weight loss.

According to the facility's policy, titled Fortification of Foods: Increasing Calories and/or Protein in the Diet, dated 2023, .Identification of residents in need of fortification will be done by the facility's Registered Dietician or the FNS Director. The physician will then order a Fortified Diet.Calories and/or protein will be added to selected food .FNS staff will be familiar with the fortification process for each item chosen to be used at the facility .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 39220

Residents Affected - Some Based on observation, interview, and record review, the facility failed to honor resident food preferences listed on their resident's meal tickets, for five of 88 residents (Residents 1, 11, 49, 75, 151), reviewed for Resident Accommodations.

This failure had the potential for resident's wishes, likes, and dislikes to be ignored.

Findings:

A lunch tray line observation was conducted in the kitchen on 1/8/25 at 12:10 P.M. The lunch meal consisted of oven crisp fish, sweet potato fries or brown rice, seasoned carrots, wheat roll, and cranberry crunch bar for dessert.

1. On 1/8/25 at 12:24 P.M., the lunch tray for Resident 1 was viewed and compared to the meal ticket. On

the plate was fish, sweet potato fries, carrots, and a wheat roll. Listed on the meal tickets was a dislike for fish. The dislike was pointed out to staff after the plate had been covered and was getting ready to load on

the metal wheeled food cart. The fish was removed by the cook and a cooked hamburger patty was place instead of the fish.

An interview was conducted with Resident 1 on 1/9/25 at 9:08 A.M., in her room. Resident 1 stated she was told by someone she had been losing weight. Resident 1 stated she did not like some of the food. Resident 1 stated if fish was served to her, she would not eat it.

2. On 1/8/25 at 12:48 P.M., the lunch tray for Resident 11 was viewed and compared to the meal ticket. On

the plate was a small piece of fish, sweet potato fries, carrots, and a wheat roll. Listed on the meal ticket was

a preference listed as Portion: Double meat, fish, eggs. The preference portion was pointed out to the staff,

after the plate had been covered and was getting ready to load on the metal wheeled food cart. The plate was given back to the cook, who added another portion of fish.

An interview was conducted with Resident 11 on 1/9/25 at 9:11 A.M., in her room. Resident 11 was sitting up

in bed, with her breakfast tray covered and untouched on the bedside table. Resident 11 stated she was in pain and did not feel like eating. Resident 11 stated she was aware she was losing weight and was trying not to. Resident 11 stated she liked to have extra meat, fish or eggs on her plate, because it was usually the only thing she ate.

3. On 1/8/25 at 1:07 P.M., the lunch tray for Resident 75 was viewed and compared to the meal ticket. A like was listed on the meal ticket as soup, with a dislike of Tomato soup. A covered bowl of tomato soup had been added to the tray, with a package of crackers on top. After the plate had been covered and the tray was getting ready to be added to the metal wheeled food cart, the dislike of tomato soup was pointed out to Kitchen Aide 1 (KA 1). KA 1 removed the soup bowl.

On 1/9/25 at 9:20 A.M., an interview was conducted with Resident 75, in her room. Resident 75 stated she loved soup, but she hated tomato soup specifically. Resident 75 stated she would not get upset if it was given to her, she just would not eat it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 4. On 1/8/25 at 1:14 P.M., the lunch tray for Resident 151 was viewed and compared to the meal ticket. The meal ticket listed the diet as Vegetarian, Fortified. The plate was viewed which consisted of a cooked meat Level of Harm - Minimal harm or patty. The cook was questioned if the patty on the plate was meat or vegetarian. The cook stated he ran out potential for actual harm of cooked veggie patty and gave no explanation of the reason meat was served in its place. The cook immediately began to cook a veggie patty, which was later plated. Residents Affected - Some

On 1/9/25 at 9:24 A.M., an interview was conducted with Resident 151 in her room. Resident 151 stated she had been a vegetarian since 4 years of age. Resident 151 stated if meat was served to her, she would be able to immediately tell. Resident 151 stated she just would not eat it (meat), and it would not upset her.

5. On 1/8/24 at 1:19 P.M. the lunch tray for Resident 49 was viewed and compared to the meal ticket. Served

on the tray was a homemade cranberry bar dessert. On the meal ticket, listed a dislike of cranberry sauce.

After the plate had been covered and the tray was getting ready to be added to the metal wheel cart, KA 1 was notified of the dislike. The dessert was removed, and vanilla ice cream was added in its place.

On 1/9/25 at 9:29 A.M., an interview was conducted with Resident 49, as he laid in bed. Resident 49 stated, No, I don't like cranberry sauce or anything related to cranberries. Resident 49 stated if it was served to him,

he just would not eat it.

An interview was conducted with the Food Nutrition Service Manager (FNS) on 1/8/24 1:50 P.M. The FNS stated she expected all preferences to be honored and respected.

An interview was conducted with the Registered Dietician (RD) on 1/8/25 at 4:05 P.M. The RD stated all resident food preferences should be honored, because it was a resident's right. The RD stated she expected all kitchen staff to review the meal cards and compare them to the plated meal during service.

According to the facility's policy, title Food Preferences, dated 2023, Resident food preferences will be adhered to within reason .Procedure: Food preferences will be obtained as soon as possible through the initial resident screen. This screening must be completed within 7 days of admission by the Food Nutrition Services Director .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49613

Residents Affected - Some Based on interview and record review, the facility failed to ensure medical records were accurate and concise for two of two residents (Residents 30 and 71), reviewed for medical records accuracy when:

1. Resident 30's medication administration records (MARs) for Creon (brand name for pancrelipase, a medication for the pancreas) incorrectly indicated nine doses were administered between 12/25/24 - 1/9/25, when the medication was not administered and was unavailable; and

2. Resident 71's Dialysis Communication Form, post assessment listed a graft, (an internal surgically created connection between an artery and a vein that allows for hemodialysis treatment), instead of a Perma-cath, (a central line inserted into a main vein).

These failures had the potential to result in inaccurate documentation of the resident's medical history and response to care.

Findings:

1. During an interview on 1/7/25 at 11:40 A.M., Resident 30 stated she had been discharged from the hospital two weeks ago with a new medication to take with meals for her pancreas. Resident 30 verified she had not received this medication since her re-admission to the facility on [DATE REDACTED].

Resident 30 had a physician order, dated 12/24/24, for Creon 24,000-76,000 units, Give 2 capsule by mouth with meals for PANCREATIC INSUFFICIENCY.

During a concurrent observation and interview on 1/7/25 at 10:50 A.M. at Medication Cart #4 with licensed nurse (LN) 4, a sealed bottle of Creon 24,000-76,000 units was noted in the top drawer. The Creon bottle was labeled for Resident 30 and indicated a pharmacy fill date of 1/6/25. LN 4 stated Resident 30 will start

this medication the following day.

During an interview on 1/8/25 at 11:40 A.M., Resident 30 stated she got her first dose of Creon with lunch on 1/7/25. Resident 30 stated she only got one dose of Creon on 1/7/25.

A review of Resident 30's January 2025 MAR indicated Resident 30 received a Creon dose on 1/7/25 at 8 A. M., before the observation of the sealed Creon bottle on 1/7/25 at 10:50 A.M.

During a concurrent interview and record review on 1/8/25 at 3:21 P.M. with the Director of Nursing (DON), Resident 30's December 2024 and January 2025 MARs were reviewed. The December 2024 MAR indicated Resident 30 received a Creon dose on the following dates and times:

- 12/25/24 at 5 P.M.

- 12/28/24 at 5 P.M.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 - 12/29/24 at 5 P.M.

Level of Harm - Minimal harm or - 12/30/24 at 5 P.M. potential for actual harm - 12/31/24 at 5 P.M. Residents Affected - Some

The January 2025 MAR indicated Resident 30 received a dose on the following dates and times:

- 1/3/25 at 5 P.M.

- 1/4/25 at 5 P.M.

The DON stated Resident 30 received the first dose of Creon on 1/7/25. The DON verified Resident 30 did not receive the doses above as documented in the MAR.

During an interview on 1/9/25 at 9:27 A.M., the DON stated documentation in the MAR is important as proof that medication was administered to the resident.

During a concurrent observation, interview, and record review on 1/9/25 at 1:13 P.M. at Medication Cart #4 with LN 5, LN 5 did a physical count of Resident 30's Creon capsules. LN 5 counted 88 capsules of Creon remaining in the bottle. LN 5 verified the sealed bottle contained 100 capsules. LN 5 verified the January 2025 MAR for Resident 30's Creon indicated a total of 16 Creon capsules had been administered to Resident 30 since 1/7/25 at 8:09 A.M. LN 5 stated the Creon bottle should have 84 capsules remaining based on the entries in the January 2025 MAR.

A review of the facility's policy and procedure titled, Charting and Documentation, dated July 2017, indicated:

.All services provided to the resident .shall be documented in the resident's medical record .The medical

record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . and .Documentation in the medical record will be objective .complete, and accurate .

39220

2. Resident 71 was admitted to the facility on [DATE REDACTED], with diagnoses which included dependence on renal dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly), per the facility's Face Sheet.

An observation and interview was conducted with Resident 71 on 1/7/25 at 2:21 P.M. Resident 71 was sitting up in bed, eating lunch. Resident 71 stated she just got back from a dialysis treatment and showed me her Perma-cath (a central line covered with a gauze), located on her upper right chest wall. Resident 71 stated

she goes to dialysis three times a week, on Tuesday, Thursday, and Saturday early in the morning.

Resident 71's clinical record was reviewed on 1/07/25:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 According to the physician orders, dated 10/22/24, monitor vital signs pre and post dialysis and right chest Perma-cath (a central line for blood access) for signs and symptoms of bleeding, swelling, redness and pain. Level of Harm - Minimal harm or potential for actual harm According to the care plan, titled Right upper chest Perma cath, undated, interventions listed included: Monitor for signs and symptoms of bleeding, swelling, redness, and pain. Notify medical doctor if observed. Residents Affected - Some

The facility's Dialysis Communication book (a form that communicates to dialysis team of resident's vital signs and Perma-cath site, dialysis documentation of what occurred while at dialysis, and a post assessment, once resident returns to the facility of vital signs and Perma-cath site) from 12/3/24 through 1/7/25 was reviewed. Of the 16 communication forms completed during that time frame, five forms were inaccurate. The five forms (dated 12/3/24, 12/27/24, 12/19/24, 12/23/24, and 1/2/25) listed on the post assessment, that Resident 71 had a graft site (an internal surgically created connection between an artery and a vein that allows for hemodialysis treatment), instead of a Perma-cath.

An interview and record review was conducted with the Director of Staff Development (DSD) on 1/8/25 at 10:45 A.M. The DSD stated dialysis grafts can only be assessed by checking the bruit (listening) and checking the thrill (feeling) the site, since the graft is internal. The DSD stated Perma-caths were assessed visually by checking for bleeding and signs of infection. The DSD stated she had been at the facility for four months and had not provided any in-services or education to Licensed nurses regarding the dialysis access sites.

An interview and record review was conducted with Licensed Nurse 7 (LN 7) on 1/8/25 at 10:53 A.M., regarding post dialysis assessments. LN 7 stated with Perma-caths there is no bruit and thrill, those can only be assessed on dialysis grafts. LN 7 was asked to review the post dialysis form she completed on 12/19/24. LN 7 stated she documented there was a dialysis graft with a bruit and thrill and did not document the resident had a Perma-cath instead. LN 7 stated she knows the difference between the two and she made an error. LN 7 stated it was important to document accurately, so everyone reviewing the record knew what was going on with the resident.

An interview and record review was conducted with LN 8 on 1/08/25 at 11:11 A.M. regarding post dialysis assessments. LN 8 stated it was very important to conduct post dialysis assessments to identify potential problems or complications. LN 8 reviewed a post dialysis assessment she completed on 12/23/24. LN 8 stated she documented Resident 71 had a bruit and thrill, which was inaccurate because the resident actually had a Perma-cath.

An interview and record review was conducted with the Director of Nursing on 1/8/25 at 11:14 A.M., of Resident 71's Dialysis Communication Forms. The DON stated post dialysis assessments were important to identify early signs of bleeding, infection, or complications. The DON stated she recently presented dialysis training to the nurses, during their annual skills assessment. The DON reviewed Resident 71's five Dialysis Communication Forms, indicating a graft was present. The DON stated the documentation was not accurate and could cause confusion to the reader.

According to the facility's policy, titled Dialysis Communication Form, undated, .9. Licensed Nurse will evaluate the resident's condition including but not limited to vital signs, dialysis access site .and skin condition upon return .and will document on the post-dialysis assessment (bottom part) communication form .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 555630 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555630 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillcrest Heights Healthcare Center 4033 Sixth Avenue Ext San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 According to the facility's policy, titled Charting and Documentation, dated July 2017, .7. Documentation of procedures and treatment will include care specific details, including: a. The date and time the Level of Harm - Minimal harm or procedure/=treatment was provided .d. How the resident tolerated the procedure/treatment . potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 555630