Health inspection·January 25, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: The facility's policy for Charting and Documentation, dated November 30, 2023, indicated that all services provided to the resident would be documented in the resident's medical record. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 13, 2024, revealed that the resident was cognitively intact. An interview with Resident 1 on January 25, 2024, at 10:30 a.m. revealed that while she was a resident she was able to leave the building without staff knowing in an attempt to go home. She stated that she observed staff exiting the building and knew just what to do in order to get out the door without it alarming. She then exited the door on the unit and walked around the building until staff found her and returned her to the building. An interview with the Social Services Director on January 25, 2024, at 12:01 p.m. revealed that she learned that Resident 1 had left the building during the morning meeting on January 22, 2024, and that she did not see anything in the resident's clinical chart to indicate that the incident occurred. An interview with Registered Nurse 2 on January 25, 2024, at 2:32 p.m. revealed that while she was feeding medications to a resident on the B wing on Sunday, January 21, 2024, she caught somebody going out the door in the solarium. She stated that she did not see who it was, just that someone had exited that door. She called for the nurse aides to go see who went through the door while she was finishing to help the resident ingest his medications. Once she was finished she had the nurse aides go out the door while she called a code green (elopement call). She stated that the nurse aides then returned inside the building with the resident and returned her to her own unit. An interview with Nurse Aide 3 on January 25, 2024, at 2:00 p.m. revealed that she heard the registered nurse yell that someone had went out the door in the solarium so she and another aide went out the door. They saw that Resident 1 was outside and they returned her to the building. She stated that the resident may have been outside the building for a few minutes at the most. There was no documented evidence in Resident 1's clinical record that she was able to get outside of the building or that she was assessed upon her return into the building. Interview with the Nursing Home Administrator and the Director of Nursing on January 25, 2024, at 4:36 p.m. revealed that there was nothing in Resident 1's clinical record indicating that she was able to get out of the building and that there should have been. 28 Pa. Code 211.5(f) Clinical Records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395241 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602 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 28 Pa. Code 211.12(d)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395241 If continuation sheet Page 3 of 3