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Complaint Investigation

Hilltop Heights Health & Rehab Center

August 11, 2025 · Johnstown, PA · 100 Woodmont Road
Citations 3
CMS Rating 1/5
Beds 120
Provider ID 395812
Healthcare Facility
Hilltop Heights Health & Rehab Center
Johnstown, PA  ·  View full profile →
Inspection Summary

HILLTOP HEIGHTS HEALTH & REHAB CENTER in JOHNSTOWN, PA — inspection on August 11, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0565
Resident Rights Deficiencies
Potential for More Than Minimal 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.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Heights Health & Rehab Center

100 Woodmont Road Johnstown, PA 15905

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Heights Health & Rehab Center

100 Woodmont Road Johnstown, PA 15905

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JOHNSTOWN, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HILLTOP HEIGHTS HEALTH & REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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