Inspection·June 2, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of five residents reviewed (Resident R38, and R42). Residents Affected - Few Findings include: A review of the facility policy Dialysis: Hemodialysis (HD) - Communication and Documentation reviewed 9/9/21 and 2/1/23, indicated staff will communicate with the certified dialysis facility regarding ongoing assessment of the resident ' s condition by monitoring for complications before and after HD treatments. Prior to leaving the nursing facility for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the resident to his/her HD facility visit. A review of the clinical record indicated that Resident R38 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and high cholesterol. A review of the Minimum Data Set (MDS - periodic assessment of care needs) date 3/8/23, indicated the diagnoses remain current A review of a physician ' s order dated 2/1/22, indicated Resident R38 was to receive dialysis three days a week on Tuesday, Thursday, and Saturday. Review of a care plan dated 7/4/21, indicated to check access site for bleeding, infection, and swelling, to confer with physician and/or dialysis center regarding changes, coordinate dialysis care with dialysis treatment center, and dialysis is on Tuesday, Thursday, and Saturday A review of the clinical record failed to reveal consistent dialysis communications sheets for treatment dates from 11/1/22 through 11/30/22, missing three of 13 dialysis complete communication forms, from 1/1/23 through 1/31/23, missing one of 13 dialysis complete communication forms, from 2/1/23 through 2/28/23, missing three of 13 dialysis communication forms, from 3/1/23 through 3/31/23, missing two of 12 dialysis communication forms, and from 5/1/23 through 5/31/23, missing one of 13 dialysis communication form A review of the clinical record indicated that Resident R42 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease, dependance on renal dialysis, and heart failure (progressive heart disease that affects pumping action of the heart muscles), hemiplegia (one-sided muscle paralysis or weakness). A review of the physician orders dated 4/6/23, indicated Resident R42 was to receive dialysis three times a week on Tuesday, Thursday, and Saturday. Review of a care plan dated 3/21/23, indicated to monitor for dry skin and apply lotion as needed, monitor for peripheral edema (swelling of your lower legs or hands), monitor labs and report to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395731 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Hills Post Acute 60 Highland Road Bethel Park, PA 15102 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctor as needed, monitor/report signs of depression, monitor/report signs of infection to access site, monitor/report to doctor signs and/or symptoms of kidney insufficiency, and failed to indicate to coordinate dialysis care with dialysis treatment center, and dialysis is on Tuesday/Thursday/Saturday. A review of the clinical record failed to reveal consistent dialysis communications sheets for treatment dates from 3/24/23 through 4/29/23, missing 13 of 17 dialysis complete communication forms. During an interview on 6/1/23, at 11:00 a.m. the Director of Nursing confirmed the facility failed to ensure the dialysis communication forms for Resident R38, and R42 were completed for each dialysis treatment day. During an interview on 6/2/23, at 8:53 a.m. Registered Nurse Employee E1 confirmed the floor staff failed to complete the dialysis communication forms prior to the resident/ ' s dialysis treatments for Resident R38, and R42. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395731 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Hills Post Acute 60 Highland Road Bethel Park, PA 15102 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R199). Residents Affected - Some Findings include: A review of the clinical record indicated Resident R199 was admitted to the facility on [DATE], with diagnoses that included myeloblastic leukemia, in remission, toxoplasma oculopathy (a disease caused by the infection with Toxoplasma gondii through congenital or acquired routes) and atrial fibrillation. A review of Resident R199's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 4/19/23, indicated the diagnosis remained current. A review of resident 199's physician orders dated 4/14/23, indicated to give 480 mg (milligrams) Letermovir (myeloid leukemia) daily. A review of resident R199's medication administration record (MAR) dated May 2022, indicated to see nurses notes on the following dates: 5/25/23, 5/26/23, 5/28/23. A review of progress notes on the above dates, indicated the medication was not available, waiting pharmacy delivery. A review of resident R199's physician orders dated 4/14/23, indicated to give 1 mg (milligrams) Tacrolimus (hx of stem cell transplant) 2 capsules daily. A review of resident R199's medication administration record (MAR) dated May 2022, indicated to see nurses notes on the following dates: 5/1/23. A review of progress notes on the above dates, indicated the medication was not available, waiting pharmacy delivery. During an interview on 6/22/23, at 11:30 a.m. the Director of Nursing confirmed the above findings and the facility failed to administer medications as prescribed by the physician for Resident R199. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395731 If continuation sheet Page 4 of 4