Health inspection·July 18, 2024

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 facility policy and documentation, resident and staff interviews, it was determined that the facility failed to demonstrate response to grievances from resident council for six of six months ( January 2024, February 2024, March 2024, April 2024, May 2024, June 2024). Residents Affected - Some Findings include: Review of the facility policy Grievance/Concern Resolution dated 1/18/24, indicated to resolve resident concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly log. Unable to review resident council meeting minutes for indication of any concerns. During an interview on 7/18/2024, at 10:30 a.m. and 1:38 p m. Residents indicated that residents' concerns are not being addressed and are on-going. During an interview on 7/18/24 at 1:34 p.m., with the previous Resident Council president it was discussed that the resident was relieved of their duties while unavailable and a new president was named in their place with no vote occurring. During an interview on 7/18/2024, at 2:48 p.m. Nursing Home Administrator and Regional Nursing Home Coordinator confirmed that residents have on-going concerns and the facility is not using concern forms or providing a resident council meeting and could not produce documentation showing they addressed the residents' concerns from previous meetings. 28 Pa. Code 201.18 e(1)Management. Page 1 of 3 395289 395289 07/18/2024 Wecare at South Hills Rehabilitation and Nrsg Ctr 201 Village Drive Canonsburg, PA 15317

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on a resident group interview and staff interview, it was determined that the facility failed to provide an ongoing program of activities based on the identified preferences/interests for seven of seven residents to enhance the resident's quality of life (Residents R100, R101, R102, R103, R104, R105 and R106). Residents Affected - Some Findings include: During an attempted review of facility activity calendars, there were no Activities Calendars for the dates May 2024- June 2024. There is a calendar in all residents rooms listing one activity each day with no time associated for these activities. During an interview on 7/18/24 at 9: 23 a.m., the Ombudsman indicated that they had been contacted by residents that were complaining that there were no activities occurring. The Ombudsman had contacted the previous Nursing Home Administrator that stated they would take care of the situation. During an interview on 7/18/24, at 1:30 p.m.,Resident Council president indicated that activities were occurring until the Activities Director was terminated April 3, 2024. During an interview on 7/18/24, at 2:30 p.m. the Nursing Home Administrator (NHA) indicated the facility was unable to locate Resident Council Group meeting minutes from January 2024- June 2024, but was able to locate Food Committee meeting minutes from January 2024- June 2024. The NHA also inidcated that Physical Therapy was covering the activities for July and will only cover during their normal work hours, leaving no activites for evenings. 28 Pa. Code: 201. 18(b)(3) Management 28 Pa. Code: 207.2(a) Administrators Responsibility 395289 Page 2 of 3 395289 07/18/2024 Wecare at South Hills Rehabilitation and Nrsg Ctr 201 Village Drive Canonsburg, PA 15317

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility policy, Resident Council Meeting minutes, facility documentation and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program for three out of six months (April, May, June). Residents Affected - Some The findings include: Review of Activities Director job description/competency/evaluation last reviewed on 1/18/24, indicated the education and qualifications for the job of Activities Director included post-secondary education in a related field is desired, and two years experience as a supervisor or long-term care Activity Director or previous work experience under a Certified Activity Consultant. Review of the previous Activity Director Employee personnel file indicated they became the activities director on 6/23/23 and then was terminated 4/3/24. Further review did not include information regarding a replacement being hired. During interviews and observations on 7/18/24 at 11:30 a.m., residents that stated there have been no activites since the previous Activities Director left and the calendar for July did not come out until the very end of June. During the interviews some of the residents have stated they missed the activity of the day. During an interview on 7/18/24, 12:00 p.m., the Nursing Home Administrator confirmed there currently was not an Activities Director qualified to oversee the Activity Program. 28 Pa. Code: 201.18(b)(3) Management. 395289 Page 3 of 3