Inspection·September 23, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of four residents reviewed (Residents 3, 4). Findings include: A facility policy for controlled substances, dated August 27, 2024, indicated that the charge nurse on duty maintains the keys to controlled substance containers. Controlled medications are to be wasted or disposed of in the presence of the nurse and a witness who also signs the disposition sheet. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 9, 2024, revealed that the resident was cognitively impaired, had pain, and received an opioid (a controlled pain medication). Current physician's orders for Resident 3, included an order for the resident to receive 5 milligrams (mg) of oxycodone every eight hours as needed for pain rated between 5-10 (a numeric scale with 0 representing no pain and 10 representing the worst pain possible). Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 3 for August and September 2024 revealed that staff signed out a dose of oxycodone for administration to the resident on August 23, 2024, at 3:00 p.m. and September 21, 2024, at 11:40 p.m. However, there was no documented evidence in the resident's Medication Administration Record (MAR) or clinical record to indicate that the oxycodone was administered to the resident on the above listed dates and times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 9, 2024, revealed that the resident was cognitively impaired, had pain, and received an opioid. Physician's orders for Resident 4, dated August 17, 2024, included an order for the resident to receive 5 mg of oxycodone every 4 hours as need for pain that was rated between 5-10. Review of the controlled drug record for Resident 3 for August 2024 revealed that staff signed out a dose of oxycodone 10 mg for administration to the resident on August 23, 2024, at 8:12 a.m., 12:37 p.m., and 4:54 p.m. However, there was no documented evidence in the resident's MAR or clinical record to indicate that the 5 mg of oxycodone was administered as ordered and the other 5 mg was wasted by two licensed nurses. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395241 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 09/23/2024 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)