Health inspection·August 11, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of Resident Council/Food Committee meeting minutes, as well as resident, staff interviews and observations, it was determined that the facility failed to make ongoing efforts to resolve grievances presented by the Resident Council/Food Committee.Findings include: Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives her meals, even with her eating in the main dining room for her lunch and supper meal.Interview with Resident 1 on August 11, 2025, at 9:29 a.m. revealed that his food is not at his desired temperature when he receives his meals. Interview with Resident 3 on August 11, 2025, at 12:38 p.m. revealed that her food is not always edible.A test tray was completed during the lunch meal on August 11, 2025, at 12:32 p.m. and the food was not palatable.Refer to F804Interview with the Director of Nursing on August 11, 2025, at 4:30 p.m. confirmed that the Resident Council/Food Committee meeting minutes from June and July 2025, revealed that the residents voiced concerns regarding their food temperatures not being at their desired temperatures when receiving their meals. Residents Affected - Some Page 1 of 4 395812 395812 08/11/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of The Pennsylvania Code, Professional and Vocational Standards, State Board of Nursing and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse assessment was completed with a change in condition for one of four residents reviewed (Resident 3). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 23, 2025, revealed that the resident was understood, could understand others, had diagnoses that included heart failure (a condition where the heart muscle cannot pump enough blood and oxygen to meet the body's needs), and received Hospice care (specialized medical care for individuals with a terminal illness, focusing on comfort, pain management, and quality of life as they approach the end of life). A care plan for the resident, dated January 12, 2025, revealed that the resident has impaired cardiovascular (refers to the heart and blood vessels) status. Staff was to monitor/ document/report any signs/symptoms of congestive heart failure (occurs when the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various tissues): dependent edema of legs and feet, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of lungs, weakness and/or fatigue, increased heart rate, lethargy (a state of tiredness, drowsiness, and lack of energy and mental alertness), and disorientation. Resident 3's Medication Administration Record (MAR) for June 2025, revealed that staff administered the resident two 325 milligram (mg) tablets of Tylenol (used to treat minor aches and pains, and reduces fever) on June 22, 2025, at 1:23 a.m. for a temperature of 99.9 degrees Fahrenheit (F), and again on June 23, 2025, at 1:07 a.m. for a temperature of 100.2 degrees F.Nursing notes for Resident 3 completed by the licensed practical nurse, dated June 23, 2025, at 1:15 a.m. revealed that the resident had a moist sounding non-productive cough, moderate nasal congestion, and hoarse voice. The resident denies a sore throat, or shortness of breath. The resident's head of bed elevated. The resident's temperature was 100.2 degrees F and the resident's as needed Tylenol was administered as per orders for elevated temperature. A nursing note completed by the licensed practical nurse at 2:42 a.m. revealed that the resident's temperature was rechecked at this time. The resident's temperature was 100.0 degrees F in her right ear, and 99.9 degrees F in her left ear. The resident's cough, congestion and hoarse voice persists. The resident's head of bed elevated. Cold oral fluids offered and encouraged. A nursing note for Resident 3 completed by the Hospice Registered Nurse, dated June 23, 2025, at 11:00 a.m. revealed that upon her arrival the resident's voice is very hoarse, and when she was asked how she was feeling she stated, Don't even ask. The resident's lungs have crackles throughout all lobes. She has a moist frequent cough with a hoarse voice. Her oxygen saturation (refers to the percentage of hemoglobin in your blood that is carrying oxygen) on room air is 90% (Normal blood oxygen saturation levels are typically between 95% and 100%. Lower levels can indicate a problem with oxygen delivery to the body's tissues) despite deep breathing. Per facility records the resident did have a low-grade temperature overnight. New orders were received from the Hospice physician for the resident to receive a Z-Pak (an antibiotic), and to increase her Lasix (treatment of edema associated with congestive heart failure), and Potassium (a mineral that your body needs to work properly) over the next three days. The Residents Affected - Few 395812 Page 2 of 4 395812 08/11/2025 Hilltop Heights Health & Rehab Center 100 Woodmont Road Johnstown, PA 15905

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility's registered nurse was given the new orders verbally and in writing.However, there was no documented evidence that the facility's registered nurse performed an assessment of Resident 3 at the time of the change in her condition. Interview with the Director of Nursing on August 11, 2025, at 4:30 p.m. revealed that she could not speak for the registered nurse that was working that night. That if a resident has a change in condition, then a registered nurse should complete an assessment of the resident. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395812 Page 3 of 4 395812 08/11/2025 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 review of policies and Resident Council/Food Committee meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures.Findings include:The facility's policy regarding food and nutritional services, dated October 24, 2024, revealed that food will be served at a palatable temperature.Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives her meals, and that is even with her eating in the main dining room for her lunch and supper meal.Interview with Resident 1 on August 11, 2025, at 9:29 a.m. revealed that his food is not at his desired temperature when he receives his meals. Interview with Resident 3 on August 11, 2025, at 12:38 p.m. revealed that her food is not always edible.Observations of the lunch meal service in the main kitchen on August 11, 2025, revealed that the [NAME] Hall cart containing the test tray left the main kitchen at 12:19 p.m., arrived on the nursing unit at 12:20 p.m., and the last resident was served at 12:31 p.m. The test tray was tasted at 12:32 p.m. and the Swedish Meatballs/Mashed Potatoes/Gravy Casserole was 131.9 degrees Fahrenheit (F), the Peas were 121.8 degrees F, the coffee was 116.6 degrees F, and the white milk was 48.4 degrees F. The meal was not palatable or at an appetizing temperature. Interview with the Regional Dietitian at the time of observation confirmed that the point of service food temperatures should be higher for the hot foods and colder for the cold foods. 28 Pa. Code 211.6(b) Dietary Services. Residents Affected - Few 395812 Page 4 of 4