Health inspection·June 12, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for peripherally-inserted central catheter catheters (PICC-long, thin tube inserted into a vein to deliver fluids or medication) for one of nine residents reviewed (Residents 3). Residents Affected - Some Findings include: The facility's policy for Infusion Maintenance, dated October 24, 2024, indicated that staff were to measure the external catheter length of PICC catheters on admission, with each dressing change, and as needed. An annual minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 13, 2025, revealed that the resident was cognitively intact, required assistance for personal care needs, received intravenous medication, and had diagnoses that included septicemia (a blood infection). Physician's orders for Resident 3, dated April 18, 2025, included orders for the resident's PICC line dressing and securement device to be changed once a day on Tuesdays and as needed. Physician's orders, dated April 18, 2025, included orders for staff to measure the catheter length with each dressing change and as needed, adding the length measurements to order notes, and to notify the physician if the catheter length has changed since the last measurement. Review of the Medication Administration Record (MAR) for Resident 3, dated May 2025, indicated that the resident had a PICC line dressing change on May 6, 13, 17, 20, 25, and 27. There was no documented evidence that the PICC line was measured at the time of the dressing change as ordered by the physician. Interview with the Director of Nursing on June 6, 2025, at 4:20 p.m. confirmed that there was no documented evidence that the PICC line was measured during dressing changes per policy and as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Page 1 of 4 395812 395812 06/12/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm 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 staff provided assistive devices to drink in accordance with the speech therapist's recommendations and/or physician's orders for one of nine residents reviewed (Resident 8). Residents Affected - Few Findings include: The facility's policy regarding adaptive equipment, dated October 24, 2024, revealed that adaptive equipment to meet the residents needs shall be determined by the therapist and be issued with a provider order (where required or needed). The primary therapist will disseminate the type of equipment and its function to other disciplines during team conference as necessary to increase carry over with proper use. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated May 9, 2025, revealed that the resident was understood, could understand others, had diagnoses that included hemiplegia (paralysis to one side of the body) following a stroke, and was on a mechanically altered diet that required a change in the texture of his food or liquids. The current care plan revealed that Resident 8 has an increased nutrition/hydration risk, and staff were to provide the resident adaptive equipment as needed/ordered: two handled spout cup (this great cup has two large handles that make it easier for users to get a more secure grasp on the cup and it has a large base to provide added stability and reduce the likelihood of tipping the cup over), maroon spoon (used to assist individuals with disabilities or conditions that make eating with a regular spoon difficult), inner lip plate (plate that reduces food spillage), and scoop bowl (bowl that allows easier access to food). Physician's orders for Resident 8, dated July 17, 2023, included an order for the resident to have a two-handled spout cup, maroon spoon, inner lip plate, and scoop bowl. A speech therapist's note for Resident 8, dated June 22, 2023, revealed that all liquids were to be consumed via a spout cup, and the resident was not to have any straws. A speech therapist's note for Resident 8, dated September 27, 2023, revealed that resident had orders for a maroon spoon and two-handled spout cup (on meal trays and at bedside) to help control bolus sizes and rate of consumption. A speech therapist's note for Resident 8, dated June 10, 2025, revealed that the resident was to continue to utilize the ordered two-handled spout cup (at meals and at bedside), inner lip plate, maroon spoon, and orders to be written for NO straws. Observations of Resident 8 during the lunch meal on June 9, 2025, at 12:05 p.m. revealed that the resident was sitting up in bed and Nurse Aide 1 assisted the resident with setting up his lunch tray. The resident had a large Styrofoam cup with a lid and straw sitting on his over-the-bed table. There was one two-handled spout cup along with a two-handled cup that had a sippy lid and a straw. The resident's meal ticket, dated June 9, 2025, indicated that the resident was not to have any straws and was to have two spout cups. 395812 Page 2 of 4 395812 06/12/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Nurse Aide 1 on June 9, 2025, at 12:35 p.m. confirmed that Resident 8 only had one two-handled cup with a spout lid and that the other cup was a two-handled cup with a sippy lid and straw, which was not in accordance with the resident's meal ticket. Observations of Resident 8 on June 9, 2025, at 3:39 p.m. revealed that the resident was in bed and had a Styrofoam cup with lid and straw on his over-the-bed table. Interview with Licensed Practical Nurse 2 on June 9, 2025, at 3:47 p.m. confirmed that Resident 8 had a Styrofoam cup with a lid and straw on his over-the-bed table. She indicated that she was not sure if the resident should have the Styrofoam cup with a lid and straw or if he should have a two-handled cup with a spout lid. Interview with the Speech Therapist on June 10, 2025, at 10:21 a.m. confirmed that Resident 8 was to have two cups with spouted lids and no straws on his lunch tray, and that he should have a two-handled cup with a spout lid at the bedside instead of the Styrofoam cup with a lid and straw. She indicated that when she discharged him from her services on June 22, 2023, she wanted him to have a two-handled cup with a spout lid and no straws and that after her evaluation on June 10, 2025, she wanted him to continue with a two-handled cup with a spout lid and no straws, because he exhibits impulsive behaviors, which increases his risk for aspiration (the inhalation of foreign material, such as food, liquid, or vomit, into the lungs or airways). 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395812 Page 3 of 4 395812 06/12/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for two of nine residents reviewed (Residents 2, 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2025, indicated that the resident was cognitively intact and required supervision with showering/bathing herself. A care plan, dated April 14, 2025, revealed that the resident was to be showered twice a week, refused showers at times, and staff were to honor her wishes. The facility's current shower schedule indicated that Resident 2 was to receive a shower/bath on Tuesdays and Saturdays. The resident's bathing records for April and May 2025 revealed that there was no documented evidence that staff provided a shower/bath to the resident or that she refused a shower/bath on Tuesday, April 22 and Fridays, April 26 and May 24, 2025. Interview with Resident 2 on June 9, 2025, at 12:00 p.m. revealed that she was receiving her showers/baths. A quarterly MDS assessment for Resident 9, dated May 22, 2025, indicated that the resident was moderately cognitively impaired and was independent with showering/bathing himself. A care plan, dated April 16, 2025, revealed that the resident was to be showered per the shower schedule and refused care at times. The facility's current shower schedule indicated that Resident 9 was to receive a shower/bath on Thursdays. The resident's bathing records for May 2025 revealed no documented evidence that staff provided a shower/bath to the resident or that he refused a shower/bath during the weeks of May 11 and 18, 2025. Interview with Resident 9 on June 9, 2025, at 12:00 p.m. revealed that her bath or shower preferences were honored and she does get showers or baths when she wants them. Interview with the Director of Nursing on June 9, 2025, at 4:20 p.m. confirmed that showers and/or baths were provided to Residents 2 and 9 per their preferences, but they were not documented for the dates listed above. 28 Pa. Code 211.12(d)(5) Nursing Services. 395812 Page 4 of 4