Inspection·February 6, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, facility provided documents and staff interview, it was determined the facility failed to follow infection control practices related to COVID 19, and risked the potential for the spread of the virus, in four of four resident rooms ( Rooms 109, 114, 225 and 242). Residents Affected - Some Findings include: Review of facility policy titled COVID-19 Testing and Management of: Symptomatic Person, Close Contacts and Outbreaks last reviewed 1/18/24, informed once the patient has been discharged , transferred, or transmission based precautions have been discontinued, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. EVS (Environmental Services) Director should complete the Discharge/Turnover Checklist when a patient is taken off precautions, transferred or discharged . Review of facility policy titled Discharge/Turnover Room Cleaning, last reviewed 1/18/24, informed resident/patient rooms are cleaned and disinfected after discharge/turnover. Turnover is defined as discontinuation of Transmission Based Precautions. The purpose is to ensure rooms are cleaned, disinfected, and prepared for admission. The information is recorded on the Discharge/Turnover Room Checklist. Review of facility provided document titled Resident Outbreak Line List for COVID-19 revealed the facility had five residents that tested positive for COVID-19 in January, 2024. Two of those residents shared a room. Room numbers associated with the resident discontinuation of transmission based precautions are as follows: room [ROOM NUMBER] - 1/20/24 room [ROOM NUMBER] - 1/14/24 room [ROOM NUMBER] - 2/6/24 room [ROOM NUMBER] - 1/18/24 During an interview on 2/5/24, at 3:00 p.m. the Accounts Manager - Environmental Services Employee E2 reported when a resident comes off of transmission based precautions the room is cleaned and disinfected. The cleaning and disinfecting information is recorded on the facility form titled Discharge/Turnover Room Checklist. The Accounts Manager - Environmental Services Employee E2 could not provide documentation of the cleaning and disinfection of Rooms 109, 114, 225, and 242 after the residents (continued on next page) 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 (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395731 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 02/06/2024 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)