Pennsylvania Department of Health
 HILLTOP HEIGHTS HEALTH & REHAB CENTER
Patient Care Inspection Results

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HILLTOP HEIGHTS HEALTH & REHAB CENTER
Inspection Results For:

There are  202 surveys for this facility. Please select a date to view the survey results.

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HILLTOP HEIGHTS HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Findings of an abbreviated complaint survey completed on June 23, 2026 at Hilltop Heights Health &; Rehab Center identified no deficient practice under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, deficient practice was identified under 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
 Plan of Correction:


§ 201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations: Based on a review facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to return a resident's personal belongings within 30 days for one of five residents reviewed (Resident 4). Findings include: The facility policy regarding personal belongings, dated March 26, 2026 revealed that once a resident is discharged from the facility their personal items shall be returned within 30 days. Clinical record review revealed the facility admitted Resident 4 on August 30, 2025, and he was transferred to the hospital on February 20, 2026. The resident was admitted to the hospital and refused readmission by the facility on March 9, 2026 when his bed hold had expired. There was no documented evidence of a written record of Resident 4's personal belongings being completed upon admission or discharge from the facility. The resident had clothing, a wallet, social security card, birth certificate, a game system, a personal laptop, headset, red tote with multiple books, a box fan, and a game controller. Interview with the Nursing Home Administrator on June 23, 2026 at 2:27 p.m. indicated that she had mailed all of the resident's personal belongings to him. She stated that she mailed three boxes to him. After further questioning she found a box containing his a wallet, social security card, birth certificate, a game system, a personal laptop, headset, and a game controller that were not sent to the resident, hidden away in an office with his name on it. She stated that she believed she had mailed all of his belongings, but then found this box on June 23, 2026 after further questioning.
 Plan of Correction - To be completed: 07/14/2026

1.) Upon location, resident's belongings were immediately shipped to him.
2.) Baseline audit of discharges within the prior 90 days has been completed to verify all resident belongings have been returned according to the regulation.
3.) Regional director of clinical services re-educated nursing home administrator and director of nursing on regulation requiring resident's personal belongings returned within 30 days.
4.) To monitor and maintain ongoing compliance, the nursing home administrator/designee will audit discharges to ensure belongings are returned within 30 days. Audits will be done weekly for 4 weeks and monthly X2 months. The results of the audits will be reviewed at the facility quality assurance and performance improvement committee for further review and recommendations.
§ 201.18(f) LICENSURE Management.:State only Deficiency.
(f) A written record shall be maintained on a current basis for each resident with written receipts for personal possessions received or deposited with the facility. The record shall be available for review by the resident or resident representative upon request.
Observations: Based on review of facility policy, clinical records and interviews with staff, it was determined that the facility failed to keep an inventory of personal belongings for one of eight residents reviewed (Resident 4). Findings include: The facility policy regarding personal belongings, dated March 26, 2026 revealed that staff were to inventory items and document in the clinical record upon admission and when resident/family alerts staff that they have acquired new items during his/her stay at facility. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 4, dated February 20, 2026, revealed that the resident was cognitively intact, required extensive assistance from staff for personal care needs, and was non-ambulatory. Nursing note for Resident 4, dated August 30, 2025 revealed that the resident was admitted for long term care from the local hospital. Nursing note for Resident 4, dated February 20, 2026 revealed that the resident was sick and transferred to the local hospital where he was admitted and later transferred to a higher level of care. Review of clinical records for Resident 4 revealed no documented evidence that an inventory of the resident's personal belongings was completed on admission or any time thereafter. Interview with the Nursing Home Administrator revealed that the facility did not record an inventory of Resident 4's personal belongings on admission or anytime thereafter.
 Plan of Correction - To be completed: 07/14/2026

1.) The facility sent back resident's belongings along with inventory list 6/23/2026.
2.) Baseline audit completed on current residents to verify inventory lists have been completed and uploaded into electronic medical record system.
3.) Director of nursing/designee re-educated nursing staff on completion of inventory sheets upon admission.
4.) To monitor and maintain ongoing compliance, the director of nursing/designee will audit new admissions to ensure inventory sheets have been completed and signed. Audits will be done weekly for 4 weeks and then monthly X2. The results of the audits will be reviewed at the facility quality assurance and performance improvement committee for further review and recommendations.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations: Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents on the day shift for two of 21 days for June 2, 2026 through June 22, 2026 Findings Include: Review of facility census data indicated that on June 8, 2026, the facility census was 88, which required 8.00 (88 residents divided by 10) NA's during the daylight shift. Review of the nursing time schedules revealed 7.37 NA's provided care on the daylight shift on June 8, 2026. On June 15, 2026, the facility census was 91, which required 8.27 NA's during the daylight shift; however, review of the time schedule revealed that 7.93 NA's provided care on the day shift. No additional excess higher-level staff were available to compensate for these deficiencies. Interview with the Nursing Home Administrator on June 23, 2026 at 3:12 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
 Plan of Correction - To be completed: 07/14/2026

1) The facility cannot retroactively correct the nurse aide (NA) ratios.
2) Moving forward, the facility will continue to schedule NA's to meet the required ratios. The facility will make every effort to use internal and external resources to meet staffing ratios. The facility offers bonuses for staff to pick up and will also utilize agency staff when necessary.
3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the staffing ratios for NAs. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate NA staff to meet the required ratios.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility NA staffing meets the required ratios each shift. Audits will be done weekly for 4 weeks and monthly X2 months. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations: Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 30 residents on the evening shift for one of 21 days (24-hour periods) reviewed. Findings Include: Review of facility census data indicated that on June 10, 2026, the facility census was 90, which required 3.0 (90 residents divided by 30) LPN's during the evening shift. Review of the nursing time schedules revealed 2.90 LPN's provided care on the evening shift on June 10, 2026. No additional excess higher-level staff were available to compensate for these deficiencies. Interview with the Nursing Home Administrator on June 23, 2026 at 3:01 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.
 Plan of Correction - To be completed: 07/14/2026

1) The facility cannot retroactively correct the licensed practical nurse (LPN) ratios.
2) Moving forward, the facility will continue to schedule LPN's to meet the required ratios. The facility will make every effort to use internal and external resources to meet staffing ratios. The facility offers bonuses for staff to pick up and will also utilize agency staff when necessary.
3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the staffing ratios for LPNs. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate LPN staff to meet the required ratios.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility LPN staffing meets the required ratios each shift. Audits will be done weekly for 4 weeks and monthly X2. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations: Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.2 hours of direct resident care for each resident for one of 21 days reviewed. Findings include: Nursing time schedules provided by the facility for the days of June 2, 2026 through June 22, 2026, revealed that the facility provided only 3.12 hours of direct care for each resident on June 6, 2026. Interview with the Nursing Home Administrator on June 23, 2026 at 3:13 p.m. confirmed that staffing was below the required minimum number of nursing care hours for the days listed above.
 Plan of Correction - To be completed: 07/14/2026

1) The facility cannot retroactively correct nursing hours per patient day (PPD)
2) Moving forward, the facility will continue to schedule to meet the required PPD. The facility will make every effort to use internal and external resources to meet staffing PPD of 3.20.
3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the requirement to provide 3.20 hours of direct care per resident. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate staffing to meet the required 3.20 PPD.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets the required PPD each day. Audits will be done weekly x4 weeks then monthly X2. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.

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