Hillview Healthcare And Rehabilitation Center

F-F584, revealed that the facility's QAPI failed to successfully implement their plan to ensure ongoing compliance with regulations regarding homelike environment.

The facility's plan of correction for a deficiency regarding the accuracy of assessment, cited during the survey ending February 1, 2024, revealed that 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

F-F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of assessments.

The facility's plan of correction for a deficiency regarding a failure to update/revise residents' care plans, cited during the survey ending February 1, 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

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating/revising residents' care plans.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 395241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395241 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 1, 2024, revealed that the facility developed a plan of correction that included completing audits Level of Harm - Minimal harm or and reporting the results of the audits to the QAPI committee for review. The results of the current survey, potential for actual harm cited under

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. Residents Affected - Few

The facility's plans of correction for deficiencies regarding ensuring that food was palatable and at proper serving temperatures, cited during the survey ending on February 1, 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

F-F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding ensuring the food was palatable and had proper serving temperatures.

The facility's plan of correction for a deficiency regarding appropriate food preparation/storage/serving, cited

during the survey ending February 1, 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

F-F812.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 395241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395241 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Some well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for eight of 54 residents reviewed (Residents 7, 8, 11, 12, 34 63, 70, 80).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated November 26, 2024, indicated that EBP's referred to the use of gown and gloves for the use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). An order for EBP's will be obtained for residents with any of the following: 1) Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO and 2) Infection or colonization with any resistant organisms targeted by

the CDC and epidemiologically important MDRO when contact precautions do not apply. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gloves and gowns.

The facility's policy regarding hand hygiene, dated November 26, 2024, indicated that hand hygiene was the primary means to prevent the spread of infections and staff were to use an alcohol based hand rub of at 62 percent alcohol or use soap and water following after contact with blood and bodily fluids and removing gloves.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 395241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395241 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident 7, dated December 6, 2024, indicated that the resident was cognitively impaired requires assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain Level of Harm - Minimal harm or urine from the bladder), and had a diagnosis of neurogenic bladder (bladder lacks control due to nerve or potential for actual harm muscle problems).

Residents Affected - Some Physician's orders for Resident 7, dated January 8, 2025, included an order for the resident to have a urinary (foley) catheter (an indwelling catheter) for neurogenic bladder. A care plan for Resident 7, dated January 22, 2024, revealed that the resident had an indwelling foley catheter for neurogenic bladder. A care plan for Resident 7, dated February 27, 2024, revealed that the resident had an MDRO related to a history of Extended-spectrum beta-lactamases (ESBL-a bacteria resistant to antibiotics) in the urine with an intervention for EBP, dated November 27, 2024. There was no documented evidence that EBP were implemented for Resident 7 until November 27, 2024.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 26, 2024, indicated that the resident was cognitive intact, was usually understood and usually able to understand others, was dependent on staff for all care needs, and had diagnoses that included quadriplegia (paralysis or weakness to both side of the body due to brain injury) and had pressure ulcers (wound caused by pressure).

Physician's orders for Resident 8, dated January 3, 2025, included an order to cleanse the right ischium (hip) with Dakin's solution 0.25 percent (wound treatment) and dry, apply collagen particles, pack with Dakins moistened gauze, and cover with bordered gauze; cleanse the right nephrostomy site (nephro - a tube placed into the bladder through the skin to drain urine) and dry, and apply a transparent film; and cleanse the left ischium and dry, apply collagen particles and cover with bordered gauze.

Observations of wound care for Resident 8 on January 17, 2025, at 10:47 a.m. revealed that Licensed Practical Nurse 5 while wearing gloves provided incontinence care to the resident after he had a bowel movement. Licensed Practical Nurse 5 changed her gloves without performing hand hygiene and using gauze cleaned the feces from this pressure ulcer on the right ischium, then cleaned the the wound with Dakin's solution and gauze, applied collagen, and applied the Dakin soaked gauze. Then Licensed Practical Nurse 5 changed her gloves at 10:48 a.m. and used saline to clean the nephro tube on the right side and applied the dressing. The resident had another bowel movement, and incontinence care was provided. Licensed Practical Nurse 5 removed all her PPE and left the room to get more supplies. Licensed Practical Nurse 5 cleaned the left buttocks with towels and water to remove the remaining feces, changed her gloves, cleaned the second pressure ulcer, applied collagen, and applied the dressing. Before leaving the room Licensed Practical Nurse 5 washed her hands with soap and water. Interview with Licensed Practical Nurse 5 on January 17, 2025, at 12:59 p.m. revealed that she did not perform hand hygiene between glove changes and dirty and clean tasks.

Interview with the Infection Preventionist on January 17, 2025, at 1:55 p.m. confirmed that hand hygiene should have been completed between glove changes and dirty and clean tasks.

A quarterly MDS assessment for Resident 11, dated November 13, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, had an indwelling urinary catheter (a thin tube inserted into the bladder to drain urine), and had diagnosis that included intervertebral disc disorder with radiculopathy, lumbar region (conditions that affect the nerve roots in the lower back and can cause pain, numbness, and weakness in the legs) and diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 395241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395241 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Physician's orders for Resident 11 dated September 19, 2024, included for the resident to have a foley catheter for urine retention (a condition that makes it difficult or impossible to empty the bladder). There was Level of Harm - Minimal harm or no documented evidence that EBP were implemented for Resident 11 until November 27, 2024. potential for actual harm

An admission MDS assessment for Resident 12, dated September 2, 2024, indicated that the resident was Residents Affected - Some cognitively impaired and had a suprapubic catheter (a thin, flexible tube inserted through a small incision in

the lower abdomen (pubic area) directly into the bladder).

A physician's order for Resident 12, dated October 17, 2024, included an order for the resident to have a suprapubic catheter due to neurogenic bladder (a condition where the nerves that control the bladder are damaged, leading to abnormal bladder function). There was no documented evidence that EBP were implemented for Resident 12 until November 27, 2024.

A quarterly MDS assessment for Resident 34, dated December 15, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, had an infection in her foot, and had reconstructive surgery following medical procedure and diabetes.

Observations and interview with Resident 34 on January 13, 2025, at 10:14 p.m. revealed that there was no PPE or signage posted outside of the room indicating that the resident was on transmission based precautions. Resident 34 indicated that she had methicillin-resistant staphylococcus aureus (MRSA infection that has been resistant to antibiotics), was on intravenous (IV - medication and fluids that are injected directly into a vein) antibiotic medication, and had surgery on her foot. Resident 34 currently had a wound vacuum (negative pressure wound therapy type to help wounds heal) in use.

Physician's orders for Resident 34, dated December 9, 2024, included an order for the resident to have contact isolation related to the MRSA to the right heel and staff are to ensure the wound vac was functioning and in place every shift. Current physician orders, dated January 13, 2025, included an order for the resident to have one gram of Vancomycin (antibiotic medication) intravenously one time a day for osteomyelitis (infection in the bone)

Interview with Registered Nurse 7 on January 13, 2025, at 12:28 p.m. indicated that the resident was on contact precautions and the signage and PPE supplies should have been available outside of the room. She remembers that they were there but were removed.

Interview with the Infection Preventionist on January 17, 2025, at 1:54 p.m. confirmed that Resident 34 was

on transmission-based precautions, the signs should have been posted, and the PPE should have been available outside of the room, but it was removed by someone.

A quarterly MDS assessment for Resident 63, dated November 6, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff with personal care needs, had diagnoses that included diabetes, and had one unstageable pressure ulcer.

Review of a skin and wound note for Resident 63, dated January 14, 2025, at 2:23 p.m. revealed that the resident was seen for follow up skin and wound care, and that the resident developed a wound to her right lateral (on the side) foot that was found on October 16, 2024. There was no documented evidence that EBP were implemented for Resident 11 until November 27, 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 395241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395241 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Healthcare and Rehabilitation Center 700 S. Cayuga Avenue Altoona, PA 16602

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An annual MDS assessment for Resident 70, dated September 2, 2024, indicated that the resident was cognitively impaired, had a feeding tube, and had diagnoses that included Parkinson's disease (a chronic Level of Harm - Minimal harm or and progressive neurological disorder that affects movement, balance, and coordination). potential for actual harm Physician's orders for Resident 70, dated August 29, 2024, included an order for the resident to receive Residents Affected - Some Jevity 1.5 (feeding formula) at 55 cubic centimeter's (cm's) per hour every shift. There was no documented evidence that EBP were implemented for Resident 70 until November 27, 2024.

A quarterly MDS assessment for Resident 80, dated June 30, 2024, indicated that the resident was cognitively impaired and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). A care plan, initiated September 22, 2023, revealed the resident had an indwelling urinary catheter.

Physician's orders for Resident 80, dated December 14, 2023, included an order for the resident to have an indwelling urinary catheter and to have it changed every 30 days. There was no documented evidence that EBP were implemented until November 27, 2024.

Interview with the Director of Nursing on January 15, 2025, at 1:29 p.m. confirmed that the facility did not start to implement EBP until November 27, 2024.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

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