Inspection visit

Health inspectionDecember 12, 2024

HILLTOP HEIGHTS HEALTH & REHAB CENTERCMS #39581224 citations on this visit

24 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 24 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 79 residents reviewed (Resident 97). Findings include: Resident 97 was admitted to the facility on [DATE], and the admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) was not completed as of December 9, 2024. An admission nursing note for Resident 97, dated November 26, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of chronic ureteropelvic junction obstruction (a blockage causing loss of kidney function), and had a nephrostomy tube (a small tube inserted into the kidney through the skin in the lower back to drain urine into a drainage bag). Observations of Resident 97 on December 9, 2024, at 11:05 a.m. revealed that the resident was being assisted with ambulation to the therapy department by Therapy Assistant 1. While assisting Resident 97, Therapy Assistant 1 was holding on to the back of the resident's gown while the back of his brief, his legs, and drainage bag were exposed and visible. Interview with Director of Therapy on December 9, 2024, at 2:18 p.m. confirmed that Resident 97 should be wearing a form of clothing to maintain dignity while being assisted with ambulation to the therapy department. Interview with the Director of Nursing on December 9, 2024, at 2:30 p.m. confirmed that Resident 97 should have had clothing on that covered him to maintain his dignity. 28 Pa. Code 201.29(c) Resident Rights. Page 1 of 34 395812 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete a thorough investigation of a fall to rule out neglect and/or abuse for one of 79 residents reviewed (Resident 39). Residents Affected - Few Findings include: The facility's policy for protection from abuse, neglect, or exploitation, dated October 24, 2024, indicated that the facility will report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, following federal and state regulations. There was to be immediate notification, but no later than two hours, to the facility's administrator, the Department of Health - Division of Nursing Care Facilities, Area Agency on Aging, and Protective Services if the events that caused the allegation involved abuse or resulted in serious bodily injury, and notification within 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. A facility policy for fall management, dated October 24, 2024, indicated that a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming force. Falls will be reviewed by an interdisciplinary team and any new interventions identified will be implemented and the care plan updated as necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 17, 2024, revealed that the resident was understood and able to understand others, was dependent on staff for chair/bed-to-chair transfers, and had diagnoses that included flaccid hemiplegia affecting his left dominant side (condition where a person has a complete lack of voluntary movement in one side of their body). A nurse's note for Resident 39, dated December 5, 2024, at 4:41 a.m., revealed that at 7:45 p.m. the resident was observed on the floor in his room between his bed and the window wall. There was no documented evidence that an investigation was initiated at the time of the fall to rule out abuse or neglect as a cause. Interview with the Director of Nursing on December 12, 2024, at 8:57 a.m. confirmed that she was unable to find an incident report or investigation for Resident 39's fall that occurred on December 5, 2024. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 2 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident, responsible party, and Ombudsman, in writing, regarding the reason for hospitalization for one of 79 residents reviewed (Resident 24). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated October 21, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 24, dated October 12, 2024, at 5:50 a.m., revealed that the resident had a large, liquid and brown emesis (ejection of stomach contents through the mouth). The physician was notified, and the resident was transferred to the hospital. There was no documented evidence that a written notice of Resident 24's transfer to the hospital was provided to the resident's responsible party and the Ombudsman regarding the reason for transfer. Interview with the Director of Nursing on December 10, 2024, at 2:15 p.m. confirmed that the facility did not provide a written notice to the resident, the resident's responsible party, or Ombudsman when a resident was transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. 395812 Page 3 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate parties were notified about the facility's bed-hold policy upon transfer to the hospital for one of 79 residents reviewed (Resident 24). Findings include: A facility policy for Bed Holds, dated October 24, 2024, included that the facility will track Medicaid bed hold days and notify appropriate parties via Medicaid bed hold letter for hospitalizations or therapeutic leave. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated October 21, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 24, dated October 12, 2024, at 5:50 a.m., revealed that the resident had a large, liquid and brown emesis (ejection of stomach contents through the mouth). The physician was notified, and the resident was transferred to the hospital. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital for Resident 24. Interview with the Director of Nursing on December 10, 2024, at 2:15 p.m. confirmed that there was no documented evidence that a bed hold notice was issued to Resident 24 or his responsible party and that it should have been. 28 Pa. Code 201.29(d) Resident Rights. 28 Pa. Code 211.5(f) Clinical Records. 395812 Page 4 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive annual Minimum Data Set assessments were completed in the required time frame for 35 of 79 residents reviewed (Residents 4, 6, 8, 11, 14, 16, 17, 22, 23, 24, 27, 29, 32, 34, 35, 36, 42, 43, 44, 47, 58, 60, 61, 65, 66, 68, 70, 71, 74, 75, 83, 84, 85, 86, 93). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an annual MDS assessment was to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days. An annual MDS assessment for Resident 4, with an ARD of October 18, 2024, was due to be completed by October 31, 2024, but was not signed as completed until November 11, 2024, which was 25 days from the ARD until completion. An annual MDS assessment for Resident 6, with an ARD of November 3, 2024, was due to be completed by November 16, but was not signed as completed until November 26, 2024, which was 24 days from the ARD until completion. An admission MDS assessment for Resident 8, with an ARD of November 2, 2024, was due to be completed by November 15, but was not signed as completed until November 25, 2024, which was 24 days from the ARD until completion. An admission MDS assessment for Resident 11, with an ARD of October 10, 2024, was due to be completed by October 23, 2024, but was not signed as completed until October 25, 2024, which was 16 days from the ARD until completion. An admission MDS assessment for Resident 14, with an ARD of September 15, 2024, was due to be completed by September 28, 2024, but was not signed as completed until October 8, 2024, which was 24 days from the ARD until completion. An admission MDS assessment for Resident 16, with an ARD of September 23, 2024, was due to be completed by October 6, 2024, but was not signed as completed until October 7, 2024, which was 15 days from the ARD until completion. An admission MDS assessment for Resident 17, with an ARD of October 18, 2024, was due to be completed by October 31, 2024, but was not signed as completed until November 14, 2024, which was 28 days from the ARD until completion. An admission MDS assessment for Resident 22, with an ARD of October 10, 2024, was due to be completed by October 23, 2024, but was not signed as completed until October 25, 2024, which was 16 days from the ARD until completion. 395812 Page 5 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An admission MDS assessment for Resident 23, with an ARD of October 9, 2024, was due to be completed by October 22, 2024, but was not signed as completed until October 24, 2024, which was 16 days from the ARD until completion. An admission MDS assessment for Resident 24, with an ARD of September 9, 2024, was due to be completed by September 22, 2024, but was not signed as completed until September 24, 2024, which was 16 days from the ARD until completion. An admission MDS assessment for Resident 27, with an ARD of October 21, 2024, was due to be completed by November 3, 2024, but was not signed as completed until November 17, 2024, which was 28 days from the ARD until completion. An admission MDS assessment for Resident 29, with an ARD of October 24, 2024, was due to be completed by November 11, 2024, but was not signed as completed until November 12, 2024, which was 15 days from the ARD until completion. An admission MDS assessment for Resident 32, with an ARD of November 2, 2024, was due to be completed by November 15, 2024, but was not signed as completed until December 1, 2024, which was 30 days from the ARD until completion. An admission MDS assessment for Resident 34, with an ARD of November 6, 2024, was due to be completed by November 19, 2024, but was not signed as completed until December 2, 2024, which was 27 days from the ARD until completion. An admission MDS assessment for Resident 35, with an ARD of October 14, 2024, was due to be completed by October 27, 2024, but was not signed as completed until November 31, 2024, which was 18 days from the ARD until completion. An admission MDS assessment for Resident 36, with an ARD of September 10, 2024, was due to be completed by September 23, 2024, but was not signed as completed until September 25, 2024, which was 16 days from the ARD until completion. An admission MDS assessment for Resident 42, with an ARD of September 11, 2024, was due to be completed by September 24, 2024, but was not signed as completed until September 30, 2024, which was 20 days from the ARD until completion. An admission MDS assessment for Resident 43, with an ARD of October 31, 2024, was due to be completed by November 13, 2024, but was not signed as completed until December 1, 2024, which was 32 days from the ARD until completion. An admission MDS assessment for Resident 44, with an ARD of September 16, 2024, was due to be completed by September 29, 2024, but was not signed as completed until October 1, 2024, which was 16 days from the ARD until completion. An annual MDS assessment for Resident 47, with an ARD of November 4, 2024, was due to be completed by November 17, 2024, but was not signed as completed until November 27, 2024, which was 24 days from the ARD until completion. An admission MDS assessment for Resident 58, with an ARD of October 18, 2024, was due to be 395812 Page 6 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed by October 31, 2024, but was not signed as completed until November 6, 2024, which was 20 days from the ARD until completion. An admission MDS assessment for Resident 60, with an ARD of September 25, 2024, was due to be completed by October 8, 2024, but was not signed as completed until October 9, 2024, which was 15 days from the ARD until completion. An admission MDS assessment for Resident 61, with an ARD of November 13, 2024, was due to be completed by November 26, 2024, but was not signed as completed until December 3, 2024, which was 21 days from the ARD until completion. An admission MDS assessment for Resident 65, with an ARD of September 30, 2024, was due to be completed by October 13, 2024, but was not signed as completed until October 15, 2024, which was 16 days from the ARD until completion. An admission MDS assessment for Resident 66, with an ARD of October 23, 2024, was due to be completed by November 5, 2024, but was not signed as completed until November 16, 2024, which was 25 days from the ARD until completion. An annual MDS assessment for Resident 68, with an ARD of November 2, 2024, was due to be completed by November 15, 2024, but was not signed as completed until November 25, 2024, which was 24 days from the ARD until completion. An admission MDS assessment for Resident 70, with an ARD of November 5, 2024, was due to be completed by November 18, 2024, but was not signed as completed until December 2, 2024, which was 28 days from the ARD until completion. An admission MDS assessment for Resident 71, with an ARD of October 15, 2024, was due to be completed by October 28, 2024, but was not signed as completed until November 6, 2024, which was 25 days from the ARD until completion. An admission MDS assessment for Resident 74, with an ARD of October 29, 2024, was due to be completed by November 11, 2024, but was not signed as completed until November 19, 2024, which was 22 days from the ARD until completion. An admission MDS assessment for Resident 75, with an ARD of October 24, 2024, was due to be completed by November 6, 2024, but was not signed as completed until November 19, 2024, which was 27 days from the ARD until completion. An admission MDS assessment for Resident 83, with an ARD of November 15, 2024, was due to be completed by November 28, 2024, but was not signed as completed until December 3, 2024, which was 19 days from the ARD until completion. An admission MDS assessment for Resident 84, with an ARD of November 8, 2024, was due to be completed by November 21, 2024, but was not signed as completed until December 2, 2024, which was 25 days from the ARD until completion. An admission MDS assessment for Resident 85, with an ARD of October 4, 2024, was due to be completed by October 17, 2024, but was not signed as completed until October 18, 2024, which was 15 days 395812 Page 7 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0636 from the ARD until completion. Level of Harm - Minimal harm or potential for actual harm An admission MDS assessment for Resident 86, with an ARD of September 21, 2024, was due to be completed by October 4, 2024, but was not signed as completed until October 14, 2024, which was 25 days from the ARD until completion. Residents Affected - Some An admission MDS assessment for Resident 93, with an ARD of September 13, 2024, was due to be completed by September 26, 2024, but was not signed as completed until September 29, 2024, which was 17 days from the ARD until completion. An interview with the Registered Nurse Assessment Coordinator (RNAC - registered nurse in charge of the MDS assessments) and the Director of Nursing on December 12, 2024, at 1:34 p.m. confirmed that the above-listed comprehensive MDS assessments were not completed within the required timeframe. 28 Pa. Code 211.5(f) Clinical Records. 395812 Page 8 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for 37 of 79 residents reviewed (Residents 1, 2, 3, 5, 9, 12, 13, 15, 18, 20, 21, 27, 28, 31, 33, 36, 37, 38, 39, 40, 45, 48, 51, 52, 54, 55, 56, 57, 59, 67, 68, 72, 73, 76, 78, 82, 85). Residents Affected - Some Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2024, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS assessment for Resident 1, with an ARD of November 2, 2024, was due to be completed on November 15, 2024; however, it was not completed until November 25, 2024, which was 10 days late. A quarterly MDS assessment for Resident 2, with an ARD of August 15, 2024, was due to be completed on August 28, 2024; however, it was not completed until September 5, 2024, which was seven days late. A quarterly MDS assessment for Resident 2, with an ARD of November 1, 2024, was due to be completed on November 14, 2024; however, it was not completed until November 20, 2024, which was six days late. A quarterly MDS assessment for Resident 3, with an ARD of August 21, 2024, was due to be completed on September 4, 2024; however, it was not completed until September 9, 2024, which was five days late. A quarterly MDS assessment for Resident 5, with an ARD of August 14, 2024, was due to be completed on August 27, 2024; however, it was not completed until August 30, 2024, which was three days late. A quarterly MDS assessment for Resident 5, with an ARD of October 28, 2024, was due to be completed on November 11, 2024; however, it was not completed until November 19, 2024, which was eight days late. A quarterly MDS assessment for Resident 9, with an ARD of October 18, 2024, was due to be completed on October 1, 2024; however, it was not completed until October 10, 2024, which was nine days late. A quarterly MDS assessment for Resident 12, with an ARD of September 19, 2024, was due to be completed on October 2, 2024; however, it was not completed until October 7, 2024, which was five days late. A quarterly MDS assessment for Resident 13, with an ARD of October 20, 2024, was due to be completed on November 2, 2024; however, it was not completed until November 12, 2024, which was 10 days late. A quarterly MDS assessment for Resident 15, with an ARD of October 1, 2024, was due to be completed 395812 Page 9 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0638 on October 14, 2024; however, it was not completed until October 16, 2024, which was two days late. Level of Harm - Minimal harm or potential for actual harm A quarterly MDS assessment for Resident 18, with an ARD of October 18, 2024, was due to be completed on October 31, 2024; however, it was not completed until November 11, 2024, which was 11 days late. Residents Affected - Some A quarterly MDS assessment for Resident 20, with an ARD of October 25, 2024, was due to be completed on November 7, 2024; however, it was not completed until November 15, 2024, which was eight days late. A quarterly MDS assessment for Resident 21, with an ARD of September 25, 2024, was due to be completed on October 8, 2024; however, it was not completed until October 14, 2024, which was six days late. A quarterly MDS assessment for Resident 27, with an ARD of September 26, 2024, was due to be completed on October 9, 2024; however, it was not completed until October 15, 2024, which was six days late. A quarterly MDS assessment for Resident 28, with an ARD of September 20, 2024, was due to be completed on October 3, 2024; however, it was not completed until October 8, 2024, which was five days late. A quarterly MDS assessment for Resident 31, with an ARD of September 25, 2024, was due to be completed on October 8, 2024; however, it was not completed until October 14, 2024, which was six days late. A quarterly MDS assessment for Resident 31, with an ARD of October 18, 2024, was due to be completed on October 31, 2024; however, it was not completed until November 11, 2024, which was 11 days late. A quarterly MDS assessment for Resident 33, with an ARD of October 19, 2024, was due to be completed on November 1, 2024; however, it was not completed until November 11, 2024, which was 10 days late. A quarterly MDS assessment for Resident 36, with an ARD of October 5, 2024, was due to be completed on October 18, 2024; however, it was not completed until October 21, 2024, which was three days late. A quarterly MDS assessment for Resident 37, with an ARD of October 23, 2024, was due to be completed on November 6, 2024; however, it was not completed until November 14, 2024, which was eight days late. A quarterly MDS assessment for Resident 38, with an ARD of September 18, 2024, was due to be completed on October 1, 2024; however, it was not completed until October 7, 2024, which was six days late. A quarterly MDS assessment for Resident 39, with an ARD of September 17, 2024, was due to be completed on September 30, 2024; however, it was not completed until October 7, 2024, which was seven days late. A quarterly MDS assessment for Resident 40, with an ARD of November 6, 2024, was due to be 395812 Page 10 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0638 Level of Harm - Minimal harm or potential for actual harm completed on November 19, 2024; however, it was not completed until November 27, 2024, which was eight days late. A quarterly MDS assessment for Resident 45, with an ARD of November 3, 2024, was due to be completed on November 16, 2024; however, it was not completed until November 26, 2024, which was 10 days late. Residents Affected - Some A quarterly MDS assessment for Resident 48, with an ARD of September 26, 2024, was due to be completed on October 9, 2024; however, it was not completed until October 14, 2024, which was five days late. A quarterly MDS assessment for Resident 51, with an ARD of August 22, 2024, was due to be completed on September 4, 2024; however, it was not completed until September 8, 2024, which was four days late. A quarterly MDS assessment for Resident 51, with an ARD of September 25, 2024, was due to be completed on October 8, 2024; however, it was not completed until October 14, 2024, which was six days late. A quarterly MDS assessment for Resident 51, with an ARD of October 28, 2024, was due to be completed on November 10, 2024; however, it was not completed until November 18, 2024, which was eight days late. A quarterly MDS assessment for Resident 52, with an ARD of October 24, 2024, was due to be completed on November 6, 2024; however, it was not completed until November 15, 2024, which was nine days late. A quarterly MDS assessment for Resident 54, with an ARD of August 16, 2024, was due to be completed on August 29, 2024; however, it was not completed until September 5, 2024, which was seven days late. A quarterly MDS assessment for Resident 55, with an ARD of August 16, 2024, was due to be completed on August 29, 2024; however, it was not completed until September 5, 2024, which was seven days late. A quarterly MDS assessment for Resident 56, with an ARD of August 20, 2024, was due to be completed on September 2, 2024; however, it was not completed until September 6, 2024, which was four days late. A quarterly MDS assessment for Resident 57, with an ARD of November 2, 2024, was due to be completed on November 15, 2024; however, it was not completed until November 25, 2024, which was 10 days late. A quarterly MDS assessment for Resident 59, with an ARD of August 23, 2024, was due to be completed on September 5, 2024; however, it was not completed until September 9, 2024, which was four days late. A quarterly MDS assessment for Resident 67, with an ARD of November 1, 2024, was due to be completed on November 14, 2024; however, it was not completed until November 20, 2024, which was six days late. A quarterly MDS assessment for Resident 68, with an ARD of August 22, 2024, was due to be completed on September 4, 2024; however, it was not completed until September 9, 2024, which was five days 395812 Page 11 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0638 late. Level of Harm - Minimal harm or potential for actual harm A quarterly MDS assessment for Resident 72, with an ARD of August 18, 2024, was due to be completed on August 31, 2024; however, it was not completed until September 6, 2024, which was six days late. A quarterly MDS assessment for Resident 72, with an ARD of November 3, 2024, was due to be completed on November 16, 2024; however, it was not completed until November 26, 2024, which was 10 days late. Residents Affected - Some A quarterly MDS assessment for Resident 73, with an ARD of August 27, 2024, was due to be completed on September 9, 2024; however, it was not completed until September 11, 2024, which was two days late. A quarterly MDS assessment for Resident 76, with an ARD of November 5, 2024, was due to be completed on November 18, 2024; however, it was not completed until November 27, 2024, which was nine days late. A quarterly MDS assessment for Resident 78, with an ARD of September 13, 2024, was due to be completed on September 26, 2024; however, it was not completed until September 30, 2024, which was four days late. A quarterly MDS assessment for Resident 82, with an ARD of September 13, 2024, was due to be completed on September 26, 2024; however, it was not completed until September 30, 2024, which was four days late. A quarterly MDS assessment for Resident 85, with an ARD of October 27, 2024, was due to be completed on November 9, 2024; however, it was not completed until November 19, 2024, which was 10 days late. An interview with the Registered Nurse Assessment Coordinator (RNAC - registered nurse in charge of the MDS assessments) and the Director of Nursing on December 12, 2024, at 1:34 p.m. confirmed that the above-listed quarterly MDS assessments were not completed within the required timeframe. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 12 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 79 residents reviewed (Residents 7, 33, 39, 49, 88). Residents Affected - Few Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Section J0100B was to be checked yes if the resident was administered any as needed pain medications during the seven-day assessment period. An annual MDS assessment for Resident 7, dated November 7, 2024, indicated that the resident did not receive as needed pain medication during the seven-day assessment period. Physician's orders for Resident 7, dated September 17, 2024, included an order for the resident to receive 0.5 milliliters (ml) of morphine concentrate every two hours as needed for pain or respiratory distress. Review of the Medication Administration Record (MAR) for Resident 7, dated November 2024, revealed that the resident was administered 0.5 ml of morphine concentrate on November 1 at 1:20 p.m. for pain, November 5 at 5:33 a.m. for pain, and on November 6 at 4:01 p.m. for pain. The RAI User's Manual, dated October 2024, revealed that the intent of Section C0100 was to determine if a Brief Interview for Mental Status (BIMS) should be conducted and the intent of Section D0100 was to determine if a mood interview should be conducted. Both assessments should be conducted unless the resident is rarely or never understood. A quarterly MDS for Resident 33, dated October 10, 2024, indicated that the resident was able to make herself understood, had the ability to understand others, and that a BIMS and a mood interview should be conducted; however, a BIMS and mood interview were not completed on the MDS assessment. A quarterly MDS for Resident 39, dated September 17, 2024, indicated that the resident was able to make himself understood, had the ability to understand others, and that a BIMS and a mood interview should be conducted; however, a BIMS and mood interview were not completed on the MDS assessment. A quarterly MDS for Resident 49, dated October 12, 2024, indicated that the resident was usually able to make herself understood, sometimes had the ability to understand others, and that a BIMS and a mood interview should be conducted; however, a BIMS and mood interview were not completed on the MDS assessment. Interview with the Director of Nursing on December 12, 2024, at 11:06 a.m. confirmed that the above-mentioned MDS assessments were coded incorrectly. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Section A2105 discharge status: The resident's discharge was to be coded the two-digit code that corresponds to the resident's discharge status. 395812 Page 13 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A discharge MDS for Resident 88, dated September 13, 2024, indicated that section A2105 was coded 04 short-term general hospital; however, a nursing note for Resident 88, dated September 13, 2024, indicated that resident was discharged home by transport service. All of his medication and belonging were sent with his mother. Interview with the Director of Nursing on December 12, 2024, at 1:35 p.m. confirmed that Resident 88 was discharged home with home health services and not to the hospital. 28 Pa. Code 211.5(f) Clinical Records. 395812 Page 14 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized preferences regarding Post Traumatic Stress Disorder (PTSD), Parkinson's Disease, or dementia for two of 79 residents reviewed (Residents 62, 68). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included Parkinson's disease. Discharge instructions for Resident 62, dated September 2, 2024, revealed that the resident was diagnosed with vascular dementia. Physician's orders for Resident 62, dated September 2, 2024, included an order for the resident to receive 25-250 milligrams (mg) carbidopa-levodopa three times per day (used to treat Parkinson's disease) and 5 mg donepezil nightly (for dementia). There was no evidence that Resident 62 had a care plan developed to address the care and treatment needs associated with his Parkinson's disease or his dementia. A comprehensive MDS assessment for Resident 68, dated November 2, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included PTSD. admission assessment for Resident 68, dated November 1, 2023, revealed that the resident suffered from PTSD and had identified triggers. As of December 12, 2024, there was no care plan developed that identified Resident 68's PTSD or his triggers. An interview with the Director of Nursing on December 12, 2024, at 9:35 a.m. confirmed that there was no care plan developed regarding Resident 62's Parkinson's disease or dementia, or Resident 68's PTSD, and there should have been. 28 Pa. Code 201.24(e)(4) admission Policy. 395812 Page 15 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 79 residents reviewed (Residents 7, 39, 72). Findings include: A facility policy for comprehensive care planning, dated October 24, 2024, indicated that the care planning coordinator will add minor changes in the resident's status to the existing care plan on a daily basis. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated November 7, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was receiving hospice care, and had diagnoses that included stroke. A care plan for Resident 7, dated December 25, 2023, indicated that the resident was receiving antidepressant medication. A care plan, dated November 1, 2023, indicated that the resident was receiving antianxiety medication. Review of the Medication Administration Record (MAR) for Resident 7, dated December 2024, revealed no documented evidence that the resident was receiving antidepressant or antianxiety medication. Interview with The Director of Nursing on December 11, 2024, at 12:44 p.m. revealed that the resident should not have had a care plan for antidepressant and antianxiety medication because she was not receiving either. A quarterly MDS assessment for Resident 39, dated September 17, 2024, revealed that the resident was understood and able to understand others, was dependent on staff for personal care needs, and had diagnoses that included flaccid hemiplegia affecting his left dominant side (condition where a person has a complete lack of voluntary movement in one side of their body). A care plan for Resident 39, dated August 31, 2023, indicated that the resident had a self-care performance deficit. An active intervention in his care plan, dated September 14, 2023, indicated that the resident was to be transferred using a mechanical lift. An active intervention in his care plan, dated March 17, 2024, indicated that the resident preferred bed baths. An active care plan, dated August 9, 2023, revealed that the resident was receiving antipsychotic medication. Physician's orders for Resident 39, dated October 8, 2024, included an order that the resident be transferred with the assist of two staff. A nurse's note, dated April 17, 2024, at 10:30 a.m., revealed that the resident requested to have showers once a week in the evening and that he was added to the shower schedule. Review of the MAR for Resident 39, dated December 2024, revealed no documented evidence that the resident was receiving antipsychotic medication. 395812 Page 16 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing on December 11, 2024, at 12:26 p.m. revealed that Resident 39's care plan was not updated to reflect his current transfer status and shower preferences and should not have had a care plan for antipsychotic medication because he was not receiving any. A quarterly MDS assessment for Resident 72, dated November 3, 2024, indicated that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnoses that included diabetes and seizure disorder. A care plan for Resident 72, dated November 5, 2023, indicated that the resident had sacral, abdominal, and right leg incision. An active intervention, dated September 13, 2024, indicated that the resident was to have wound vac (a medical treatment that uses negative pressure to promote wound healing) dressing changes completed as ordered. A nurse's note for Resident 72, dated September 23, 2024, at 2:16 p.m., indicated that the resident had new wound care orders that included discontinuing the wound vac. Interview with The Director of Nursing on December 12, 2024, at 12:10 p.m. revealed that Resident 72's care plan was not updated when his wound vac was discontinued as it should have been. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 17 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews, resident interviews, and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene, by failing to provide showers as scheduled for one of nine residents reviewed (Resident 5). Residents Affected - Some Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, required extensive assistance from staff for personal hygiene, was dependent on staff for bathing, and had diagnoses that included Parkinson's disease. The resident's current shower schedule indicated that he was to receive a shower weekly on Mondays. However, the resident's bathing records for August, September, October, November, and December 2024 revealed that the resident received only three showers since August 1, 2024. Interview with Resident 62 on December 9, 2024, at 11:20 a.m. revealed that he has not been getting a shower, despite asking for one. He stated that he has not been showered at least once a week and that he would like to be. Interview with the Director of Nursing on December 11, 2024, at 3:07 p.m. confirmed that there was no documented evidence regarding why Resident 62 was not getting his showers and that she talked to him and he would like to be showered at least weekly. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 18 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for one of 79 residents reviewed (Resident 7). Residents Affected - Few Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated November 7, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was receiving hospice care, and had diagnoses that included stroke. Physician's orders for Resident 7, dated August 28, 2024, included an order for the resident to have her right dorsal (top) foot and right mid planter (bottom) foot cleansed with wound cleaner, swabbed with betadine (solution used to prevent infections), and secured with nonwoven gauze daily. Physician's orders, dated November 14, 2024, included orders for the resident to receive 15 milligrams (mg) of immediate release morphine (pain medication) 30 minutes prior to wound care every day. Review of the Medication Administration Record (MAR) for Resident 7 indicated that the morphine was scheduled for administration at 8:00 a.m. daily. However, the resident's wound care was scheduled to be completed between 6:00 a.m. and 6:00 p.m. daily. Review of Resident 7's MAR on December 11, 2024, at 8:38 a.m. revealed that the resident's morphine that was to be given prior to wound care at 8:00 a.m. was documented as administered. Observations of Resident 7 on December 11, 2024, at 10:22 a.m. revealed that staff was providing wound care to the resident's right foot. There was no documented evidence that morphine was provided 30 minutes prior to the wound care. Interview with Resident 7 on December 10, 2024, at 2:20 p.m. revealed that her wound care was completed at different times each day, depending on how busy the staff was. Interview with the Director of Nursing on December 11, 2024, at 3:19 p.m. confirmed that there was no documented evidence that Resident 7 received pain medication 30 minutes prior to her wound care as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395812 Page 19 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 79 residents reviewed (Resident 39) who required assistance from staff for transfers. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 17, 2024, revealed that the resident was understood and able to understood others, was dependent on staff for chair/bed-to-chair transfers, and had diagnoses that included flaccid hemiplegia affecting his left dominant side (condition where a person has a complete lack of voluntary movement in one side of their body). Physician's orders for Resident 39, dated October 8, 2024, included that the resident be transferred with the assist of two staff. A nurse's note for Resident 39, dated December 5, at 4:41 a.m., revealed that on December 4, 2024, at around 7:45 p.m. the resident was observed to be on the floor in his room between the bed and the window wall. He was assessed, had no injuries, and was assisted back to bed with the use of a mechanical lift. An undated witness statement provided by Nurse Aide 2, revealed when I walked in the room, he was at the tip of his chair about to fall off, I attempted to put him in his bed, but his pants got stuck on the break. He had my arms so I couldn't unhook him. I then lowered him to the ground with his back against the wall. Interview with Resident 39 on December 11, 2024, at 8:53 a.m. revealed that he fell last week trying to get into bed. One nurse aide was helping him. He did not get hurt. Resident 39 reported that he is sometimes transferred with one staff member and sometimes transferred with two staff members and prefers to be transferred by two staff because he feels more comfortable with two staff helping. Interview with the Director of Nursing on December 12, 2024, at 8:57 a.m. revealed that a fall re-enactment and interview with Nurse Aide 2 completed on December 11, 2024, by the facility revealed that the resident was not transferred with two staff members as ordered by the physician because Nurse Aide 2 felt the resident would have fallen out of his chair if she had not tried to transfer him to his bed. She was unable to reposition him in his chair and attempted to transfer him to his bed rather than lower him to the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395812 Page 20 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident's weight was obtained and documented as per facility policy for a resident with tube feedings for one of 79 residents reviewed (Resident 1) and failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely intervention for weight loss for one of 79 residents reviewed (Resident 62). Residents Affected - Some A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 2, 2024, indicated that the resident was rarely/never understood, was dependent on staff for all care, was receiving tube feedings (delivers liquid nutrition through a flexible tube that goes directly into your stomach), and had diagnoses that included traumatic brain injury (disruption of normal function of the brain caused by an outside force). A facility policy for residents' weights revealed that weights are to be obtained routinely in order to monitor nutritional health over time. Residents will be weighed monthly unless ordered otherwise by a provider. Weights will be recorded in the electronic health record. A care plan for Resident 1, dated July 14, 2023, indicated that the resident was receiving nothing by mouth, required tube feedings, and had a goal that the resident will be free of significant weight changes every month per weight reports. Review of Resident 1's weight record revealed no documented evidence that the resident's weight was obtained in January, March, May, or June 2024. Interview with the Director of Nursing on December 12, 2024, at 8:54 a.m. confirmed that Resident 1 should have been weighed monthly but was not weighed in January, March, May, or June 2024. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included Parkinson's disease. The resident's weight records revealed that he experienced a 117.9-pound weight loss in four months when his weight dropped from 310.7 pounds on August 1, 2024, to 192.8 pounds on October 6, 2024. According to Resident 62's weight record for August 2024 through October 2024, the resident weighed 310.7 pounds on August 1, 2024; 311.5 pounds on August 6, 2024; 309.5 pounds on August 13, 2024; 202.4 pounds on August 22, 2024; 208.7 pounds on August 28, 2024; 204 pounds on September 1, 2024; 194.4 pounds on September 10, 2024; 192.9 pounds on September 17, 2024; 192.6 pounds on September 24, 2024; 192.8 pounds on October 1, 2024; and 192.8 pounds on October 6, 2024. A dietary note, dated August 26, 2024, indicated that the resident's weights from August 1, August 6, August 13, and August 22 were not accurate and that he would be reassessed. A dietary note, dated September 25, 2024, indicated that the resident had a 7.6 percent weight loss in 30 days; however, the accuracy of the weights that were obtained was questionable. There was no documented evidence that the resident's weight loss was addressed at that time. There was no documented evidence that any interventions were developed and implemented to prevent 395812 Page 21 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some further unplanned weight loss for Resident 62, or that the physician was notified regarding his 117.9-pound weight loss. As of December 12, 2024, there were no further weights obtained after October 6, 2024, to assess the accuracy of previous weights obtained or to address the weight loss. Interview with the Director of Nursing on December 12, 2024, at 10:19 a.m. confirmed that there was no documented evidence that Resident 62's weight loss was addressed by the dietician or the physician and that it should have been. 28 Pa. Code 211.12(d)(3) Nursing Services. 395812 Page 22 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on a review of clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for residents with a tube feed (surgically implanted tube for artificial feeding) for two of 79 residents reviewed (Residents 66, 78). Findings include: The facility's policy regarding tube feeds, dated October 24, 2024, revealed that staff would maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. A quarterly Minimum Data Set (MDS a mandated assessment of a resident's abilities and care needs) assessment for Resident 66, dated November 5, 2024, revealed that the resident is severely cognitively impaired, requires extensive assistance from staff for all daily care needs, had diagnoses that included stroke, and had a feeding tube (tube surgically inserted into the stomach for artificial feeding). The resident's weight records, dated November 2024, revealed that he experienced a 14-pound weight loss in 15 days. On November 12, 2024, Resident 66 weighed 145 pounds and on November 27, 2024, the resident weighed 131 pounds, indicating a 14-pound weight loss in 15 days. There was no documented evidence that any interventions were developed and implemented to prevent further unplanned weight loss for Resident 66, or that the physician was notified regarding his 14-pound weight loss in 15 days. Interview with the Director of Nursing on December 12, 2024, at 10:19 a.m. confirmed that as of December 12, 2024, Resident 66's weight loss had not been addressed by the dietician or physician. A quarterly MDS assessment for Resident 78, dated September 13, 2024, revealed that the resident is cognitively intact and required assistance from staff for all daily care needs, had diagnoses that included stroke, and had a feeding tube (tube surgically inserted into the stomach for artificial feeding). The resident's weight records, dated August 22, 2024, revealed that he experienced a 13-pound weight loss in 17 days. On August 5, 2024, Resident 78 weighed 149 pounds and on August 22, 2024, the resident weighed 136 pounds, indicating a 13-pound weight loss in 17 days. There was no documented evidence that any interventions were developed and implemented to prevent further unplanned weight loss for Resident 78, or that the physician was notified regarding his 13-pound weight loss in 17 days. Interview with the Director of Nursing on December 12, 2024, at 11:30 a.m. confirmed that as of December 12, 2024, Resident 78's weight loss had not been addressed by the dietician or physician. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 23 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to obtain a physician's order for oxygen therapy for one of 79 residents reviewed (Resident 5). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 28, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included chronic respiratory failure. A care plan for Resident 5, dated July 26, 2024, indicated that the resident required oxygen therapy for chronic respiratory failure, and that staff were to explain the importance of keeping the oxygen at the prescribed setting, stressing more oxygen may not be better. Observations of Resident 5 on December 9, 2024, at 10:50 a.m. and December 12, 2024, at 12:59 p.m. revealed that the resident was sitting in her wheelchair in the hallway with oxygen being administered at four liters per minute. Observations on December 11, 2024, at 8:42 a.m. revealed that the resident was lying in bed with oxygen being administered at four liters per minute. Review of clinical records for Resident 5, including physicians' orders and treatment administration records, revealed no documented evidence that physician's orders were obtained for the resident's oxygen therapy. Interview with Director of Nursing on December 12, 2024, at 1:12 p.m. confirmed that there was no documented evidence that a physician's order was obtained for Resident 5's use of oxygen. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395812 Page 24 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of policies, a pharmacy delivery schedule, a list of emergency medications kept at the facility, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management for one of 22 residents reviewed (Resident 62). Residents Affected - Few Findings include: The facility's policy regarding pain management, dated January 14, 2019, indicated that staff would implement the pain management program, including evaluation/re-evaluation for residents experiencing either acute or chronic pain. The policy also indicated that pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. Staff were to obtain information from the evaluation process to determine what level of pain will interfere with the resident's quality of life and prohibit him/her from carrying out normal life activities. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, required extensive assistance from staff for personal hygiene, had moderate pain occasionally, and had diagnoses that included Parkinson's disease. Current physician's order for Resident 62 included an order for 10 micrograms/hour (mcg/hr) Butran's patch (pain patch), change every seven days for pain. Resident 62's Medication Administration Record (MAR), dated December 2024, revealed that the Butran's patch was not available on December 4 or December 11, 2024; therefore, the resident had not had a pain patch on since November 27, 2024. An interview with Resident 62 on December 9, 2024, at 11:32 a.m. revealed that he has pain frequently and does not get relief from his current medications. He stated that the last two weeks he had more pain than usual. There was no documented evidence that nursing staff made efforts to provide effective pain management for Resident 62 when his pain patches were not available. Interview with the Director of Nursing on December 12, 2024, at 10:21 a.m. revealed that she called the pharmacy and there was a problem with Resident 62's insurance. They stated that the Butran's patches would be sent to the facility that evening for the resident. She stated there was no evidence that the staff offered the resident any other pain medication for relief. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395812 Page 25 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually, based on hire dates, for three of three nurse aides reviewed (Nurse Aide 3, Nurse Aide 4, Nurse Aide 5). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 3 was due July 1, 2024. As of December 12, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 3. A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 4 was due July 1, 2024. As of December 12, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 4. A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 5 was due July 1, 2024. As of December 12, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 5. Interview with the Nursing Home Administrator on December 12, 2024, at 12:45 p.m. confirmed that there was no evidence that the annual performance evaluation for Nurse Aide 3, Nurse Aide 4, and Nurse Aide 5 was completed as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. 395812 Page 26 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

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 maintain accountability for controlled medications (drugs with the potential to be abused) for one of 76 residents reviewed (Resident 89). Findings include: The facility's policy regarding controlled substance disposal, dated October 24, 2024, indicated that the destroying/disposal of controlled drugs should be conducted according to federal and state regulations. Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and a witnessing licensed professional. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated October 27, 2024, revealed that the resident was cognitively impaired, received an antianxiety medication, and had diagnoses that included Metabolic Encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood the affects the brain). Physician's orders for Resident 89, dated October 28, 2024, included an order for the resident to receive 1 milligram (mg) of Lorazepam (an antianxiety medication) every four hours as needed for anxiety and restlessness. The Medication Administration Record (MAR) for Resident 89, dated October 2024, revealed that there was no documentation to indicate that the resident received any doses of Lorazepam. As of December 12, 2024, there was no controlled drug count record (tracks each dose of a controlled medication). Resident 89 ceased to breath on October 29, 2024, and there was no documentation that Lorazepam was destroyed or disposed of per facility policy. Interview with the Director of Nursing on December 12, 2024, at 11:30 a.m. confirmed that there was no documentation the Lorazepam was destroyed or disposed of and there should have been. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395812 Page 27 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 79 residents reviewed (Resident 72). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 72, dated November 3, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, received routine and as needed pain medication, and had diagnosis that included diabetes. Review of a pharmacy Medication Regimen Review (MRR) recommendation for Resident 5, dated July 7, 2024, recommended that the physician consider ordering Senna (stimulant laxative to treat constipation) once daily at bedtime, while continuing to monitor for signs and symptoms of constipation. There was no documented evidence that the pharmacy recommendation was reviewed by the physician. Interview with the Director of Nursing on December 12, 2024, at 1:38 p.m. confirmed that there was no documented evidence that the physician addressed the pharmacy MRR for Resident 72 and should have. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395812 Page 28 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Residents Affected - Some Findings include: The facility's policies regarding menu planning, as well as sanitization, dated October 24, 2024, indicated that regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. The facility's written and posted weekly menu for the lunch meal on December 8, 2024, revealed that the residents were to receive baked fish. The recipe of baked cod, undated, indicated that the cod filets were to be baked with margarine, salt, and white pepper. A test tray completed on November 11, 2024, at 12:12 p.m. revealed that the pureed baked fish was snow white in color when compared to the regular diet portion of baked fish, and there were no seasonings added to the pureed fish. The regular diet portion of baked fished had visible seasonings and margarine added. The pureed baked cod was bland tasting and was not as flavorful. Interview with the Corporate Dietary Director on December 11, 2024, at 2:20 p.m. confirmed that the pureed baked cod should have been prepared with the same ingredients, and that seasoning may not have been added to the pureed fish, as it appeared to be whiter in color compared to the regular portion of baked fish. 28 Pa. Code 211.6(a) Dietary Services. 28 Pa. Code 201.29(j) Resident Rights. 395812 Page 29 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable. Residents Affected - Some Findings include: Interview with a group of residents on December 10, 2024, at 11:15 a.m. revealed that the food delivered to the resident rooms was served cold. Observations in the kitchen for the lunch meal service on December 11, 2024, at 11:58 a.m. revealed that a test tray left the kitchen and arrived on the North hall at 12:00 p.m. The lunch meal on December 11, 2024, consisted of baked fish, broccoli rice casserole, jello, milk, and coffee. The pureed meal had pureed broccoli noodles instead of the casserole. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:12 p.m. The test tray on December 11, 2024, at 12:12 p.m. revealed that the temperature of the baked fish was 114.2 degrees Fahrenheit (F), the pureed baked fish was 104.2 degrees F, the pureed broccoli was 102 degrees F, the pureed noodles was 105.3 degrees F, the broccoli rice casserole was 128.5 degrees F, the jello was 46.4 degrees F, the milk was 43.3 degrees F, and the coffee was 116.6 degrees F. The baked cod, pureed cod, pureed noodles, and pureed broccoli were cool and unappetizing. Interview with the Corporate Dietary Manager on December 11, 2024, at 12:20 p.m. confirmed that foods should be served to residents at proper and palatable temperatures. 28 Pa. Code 211.6(b) Dietary Services. 395812 Page 30 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions. Residents Affected - Some Findings include: The facility's policies regarding storage of refrigerated foods, as well as sanitization, dated October 24, 2024, indicated that food would be stored in order to maximize food safety and quality, all refrigerated foods prepared and held for more than 24 hours would be marked to indicate the date the food would be consumed or discarded by, and that temperatures for refrigeration were to be between 35 to 39 degrees Fahrenheit with thermometers checked at least twice a day. Observations in the main kitchen on December 9, 2024, at 8:47 a.m. revealed that the walk-in refrigerator had three bags of brussel sprouts with one bag that had a use-by date of November 19, 2024, and the other two had a use-by date of November 25, 2024. The brussel sprouts appeared discolored and had increased moisture in the bags. There was an undated silver tray of cooked chicken tenders, and a bag of cilantro that appeared discolored and had increased moisture in the bag that was dated as opened October 23, 2024, and a use by date of November 7, 2024. Interview with Cook/Dietary Aide 6 on December 9, 2024, at 8:58 a.m. confirmed that the chicken tenders should have been dated when prepared and that the expired food should have been discarded. The facility currently did not have a dietary manager and the dietitian and the corporate dietary manager were handling kitchen tasks. Observations in the main kitchen on December 9, 2024, at 9:02 a.m. revealed that there was a large stand mixer with dried, yellow food debris on the bowel and mixing attachment. The meat slicer had dried food debris as well. Interview with Cook/Dietary Aide 6 on December 9, 2024, at 9:04 and 9:20 a.m. confirmed that neither machine was used that morning, were covered in plastic, and needed cleaned. Observations of the dry storage in the main kitchen on December 9, 2024, at 9:07 a.m. revealed that there was a large container of flour on the shelf. There was no lid and the flour was exposed to air. There were two boxes of food (a box of rolled oats and a box of canned mandarin oranges) sitting directly on the floor. Interview with the dietitian on December 9, 2024, at 9:17 a.m. confirmed that there should be no food on the floor and the flour should be covered. Observations of the dry storage in the main kitchen on December 10, 2024, at 2:01 p.m. revealed that there was no thermometer in the milk cooler. Interview with Corporate Dietary Manager on December 9, 2024, at 2:05 p.m. confirmed there was no thermometer in the milk cooler, and after searching, it was found in another cooler. 28 Pa. Code 211.6(f) Dietary Services. 395812 Page 31 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending January 18, 2024; February 23, 2024; June 19, 2024; September 19, 2024; and October 21, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 12, 2024, identified repeated deficiencies related to failure provide notice of bed hold policy, failure to complete comprehensive assessments timely, failure to develop resident care plans, failure to provide activities of daily living care to dependent residents, failure to provide quality of care, failure to provide feeding tube management, failure to maintain a complete and accurate account of controlled medications, failure to label and store drugs and biologicals, and failure to provide menus prepared in advance and menus followed to meet residents' needs The facility's plan of correction for a deficiency regarding bed hold notices, cited during the surveys ending January 18, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F625, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding notification of a bed hold notices. The facility's plan of correction for a deficiency regarding the timely completion of comprehensive assessment, cited during the survey ending January 18, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F636, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding timely comprehensive assessments. The facility's plans of correction for deficiencies regarding developing and implementing comprehensive care plans, cited during the surveys ending January 18, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans. The facility's plan of correction for a deficiency regarding activities of daily living care to dependent residents, cited during the surveys ending February 23, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F677, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding activities of daily living care to dependent residents. The facility's plan of correction for a deficiency regarding quality of care, cited during the 395812 Page 32 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few surveys ending January 18, 2024 and September 19, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding feeding tube management, cited during the surveys ending January 18, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F693, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding feeding tube management. The facility's plan of correction for a deficiency regarding failure to maintain a complete and accurate accounting of controlled medications, cited during the survey ending January 18, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining a complete and accurate accounting of controlled medications. The facility's plan of correction for a deficiency regarding menus being prepared in advance and followed to meet residents' needs, cited during the survey ending October 21, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F803, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding menus being prepared in advance and followed to meet residents' needs. Refer to F625, F636, F656, F677, F684, F693, F755, F803. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395812 Page 33 of 34 395812 12/12/2024 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's main kitchen. Residents Affected - Few Findings include: Observations in the main kitchen on December 9, 2024, at 8:47 a.m. revealed that the steamer had a note that it was broken and not to use it. Interview with the Corporate Dietary Manager on December 10, at 1:38 p.m. revealed that she has been with the company for about one and a half years and the steamer has not worked since she has been there. The steamer was not repairable and the facility was in the process of reordering a new one. Interview with the Nursing Home Administrator on December 11, 2024, at 3:15 p.m. confirmed that the steamer was not functioning and that the facility was currently receiving price quotes about purchasing a new steamer. 28 Pa. Code 207.2 (a) Administrator's Responsibility. 395812 Page 34 of 34

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Citations

24 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0636GeneralS&S Epotential for harm
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
0638GeneralS&S Epotential for harm
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0730GeneralS&S Dpotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0867GeneralS&S Dpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0908GeneralS&S Dpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0623GeneralS&S Bno actual harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Bno actual harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.

FAQ · About this visit

Common questions about this visit

What happened during the December 12, 2024 survey of HILLTOP HEIGHTS HEALTH & REHAB CENTER?

This was a inspection survey of HILLTOP HEIGHTS HEALTH & REHAB CENTER on December 12, 2024. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HILLTOP HEIGHTS HEALTH & REHAB CENTER on December 12, 2024?

Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed July 6, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 12, 2024