Health 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 Page 1 of 2 395731 395731 02/06/2024 South Hills Post Acute 60 Highland Road Bethel Park, PA 15102

F 0880 were discontinued from transmission based precautions. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/5/24, at 3:15 p.m. the Account Manager - Environmental Service Employee E2 confirmed the facility failed to follow infection control practices related to COVID 19, and risked the potential for the spread of the virus. Residents Affected - Some 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395731 Page 2 of 2