Health inspection·March 27, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's responsible party was given the opportunity to participate timely in the development and implementation of a person-centered care plan for one of six residents reviewed (Resident 2). Findings include: A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated December 23, 2024, revealed that the resident was understood, could understand others, and required staff assistance for her Activities of Daily Living (ADL's). Information provided by the facility revealed that the facility conducted a care plan conference with Resident 2 on October 25, 2024. Interview with the Social Worker and the Registered Nurse Assessment Coordinator (RNAC - registered nurse in charge of the MDS assessments) on March 24, 2025, at 7:15 p.m. revealed that care plan conferences are held quarterly with the residents and resident's responsible party. They indicated that they send out invitations to the resident's responsible party to attend the care plan conferences, and if the family does not attend they would reach out to the resident's responsible party to discuss the resident's care needs. However, as of March 25, 2025, there was no documented evidence that the facility conducted a care plan conference with the resident and/or the resident's responsible party in January 2025. Interview with the Director of Nursing on March 25, 2025, at 3:45 p.m. confirmed that there was no documented evidence that the facility conducted a care plan conference with the resident and/or the resident's responsible party in January 2025. Page 1 of 4 395812 395812 03/27/2025 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 observations and 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 two of six residents reviewed (Residents 1, 2). Findings include: The facility's policy regarding care plans, dated October 24, 2024, indicated that the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated March 5, 2025, revealed that the resident was cognitively intact, was at risk for pressure sore development, and had a pressure-relieving device on his bed. The resident's current care plan indicated that the resident was to have an alternating pressure-relief mattress (air mattress that redistributes weight and improves circulation). Observations of Resident 1 on March 24, 2025, at 7:48 p.m. revealed that Resident 1 did not have an alternating air mattress in place. Interview with the Director of Nursing on March 24, 2025, at 8:30 p.m. confirmed that Resident 1 did not have an alternating air mattress in place and his care plan needed updated. A significant change in status MDS assessment for Resident 2, dated December 23, 2024, revealed that the resident was understood, could understand others, and required staff assistance for her Activities of Daily Living (ADL's). The resident's current care plan indicated that the resident's preference was to receive a shower two times per week. A nursing note for Resident 2, dated January 29, 2025, revealed that the resident refused her shower today, and that she gets showered on Mondays per her request. However, as of March 25, 2025, there was no documented evidence that Resident 2's care plan was updated/revised to reflect her current preference of receiving her showers one time a week. Interview with the Director of Nursing on March 25, 2025, at 3:42 p.m. confirmed that there was no documented evidence that Resident 2's care plan was updated/revised to reflect her current preference of receiving her showers one time a week. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 2 of 4 395812 03/27/2025 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with the services necessary to maintain good oral hygiene at bedtime for three of six residents reviewed (Residents 2, 5, 6). Residents Affected - Some Findings include: The facility's policy regarding evening care, dated October 24, 2024, revealed that nursing staff would offer evening care to residents to promote personal hygiene, comfort, relaxation, and safety. Staff were to assemble oral care supplies and assist residents with oral care. A list of residents with dentures provided by the facility included Resident's 2, 5, and 6. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated December 23, 2024, revealed that the resident was understood, could understand others, and required staff assistance for set-up with oral care. The resident's care plan, dated January 9, 2025, revealed that the resident was to receive Activities of Daily Living (ADL's) on the day, evening, and night shift. Resident 2's oral/denture care documentation for February and March 2025 revealed that there was no documented evidence that oral/denture care was provided at bedtime on February 27 and 28, 2025, and March 1, 2, 6, 7, 9, 12, 15, 18, 20, 21, 22, and 23, 2025. There was no documented evidence regarding why oral/denture care was not provided at bedtime. An admission and quarterly MDS assessment for Resident 5, dated June 4, 2024, and January 31, 2025, revealed that the resident was able to understand and be understood, was cognitively intact, had no natural teeth, and required staff assistance for set-up with oral care. The resident's care plan, dated January 9, 2025, revealed that the resident was to receive ADL's on the day, evening, and night shift. Resident 5's oral/denture care documentation for February and March 2025 revealed that there was no documented evidence that oral/denture care was provided at bedtime on February 27, 28, and March 1, 4, 7-10, 12, 13, 15-21, 23, 24, and 25, 2025. There was no documented evidence regarding why oral/denture care was not provided at bedtime. A quarterly MDS assessment for Resident 6, dated January 12, 2025, revealed that the resident was cognitively impaired, had no natural teeth, and was dependent on staff for oral care. Resident 6's oral/denture care documentation for March 2025 revealed that there was no documented evidence that oral/denture care was provided at bedtime on March 1-3, 6, 7, 9, 10, 14-16, 20, and 22-24, 2025. There was no documented evidence regarding why oral/denture care was not provided at bedtime. Interview with the Director of Nursing on March 26, 2025, at 2:15 p.m. confirmed that there was no documented evidence that staff provided oral care at bedtime for Residents 2, 5, and 6. 395812 Page 3 of 4 395812 03/27/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0677 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395812 Page 4 of 4