Pennsylvania Department of Health
SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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SOUTH HILLS REHABILITATION AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a complaint survey completed on March 4, 2024, it was determined that South Hills Rehabilitation and Wellness was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a safe, comfortable, home-like environment for one of two resident shower rooms (C-Wing shower room).

Findings include:

Review of facility policy "Clean, Safe and Orderly Environment," last reviewed 1/17/23, indicated the facility will be maintained in clean, safe, and orderly manner. Housekeeping, Laundry, and Maintenance services will be provided properly with precautions taken to prevent infection and cross contamination.

During an observation on 3/1/24, at 1:00 p.m. the following was noted in the C-Wing shower room:
-First shower area: Numerous partially used, resident specific hygiene items (shampoo, body wash, deodorant) on the shower floor, nail clippers on the floor, and a plastic caddy with hygiene items in it. A plastic cover for a curtain rod was on the floor of the shower. Numerous adhesive stickers from the tops of baby powder containers adhered to the shower wall. A brown substance that appeared to be feces was on the shower floor.
-Second shower area: A large wheelchair cleaning machine was in the shower area. On top of the wheelchair cleaning machine were (2) disposable briefs, resident clothing, towels, (12) containers of various hygiene items, a box of gloves, and (2) disposable razors.
-Third shower area: The waste receptacle for a bedside commode with feces.
-Fourth shower area: (3) bottles partially used body wash, (2) cans of shaving cream, (1) partially used bottle of shampoo on the handrail, (1) used razor, and a waste receptacle for a bedside commode filled with water.

During an interview on 3/1/24, at 12:20 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to maintain a safe, comfortable, home-like environment for one of two resident shower rooms.

28 Pa. Code 207.2(a) Administrator's responsibility.

28 Pa. Code 201.18(b)(1) Management.

Plan of Correction - To be completed: 03/19/2024

1. Hygiene items were removed from the floor, nail clippers were removed from the floor, plastic caddy was removed, plastic cover for curtain rod was removed, adhesive stickers were removed from wall and the shower room floor was cleaned in the first shower area in the C-Wing shower room. The items were removed on top of the large wheelchair cleaning machine in the second floor shower area in the C-Wing shower room. The waste receptacle for the bedside commode was removed and cleaned in the third shower area in the C-Wing shower room. The bottles of body wash, cans of shaving cream, the used razor and the shampoo was removed from the fourth shower room in the C-Wing shower room. The waste receptacle for the bedside commode was removed and cleaned from the fourth shower room in the C-Wing shower room.
2. The facility will maintain a clean, homelike environment for the residents. The Maintenance Director, Housekeeping Director and Nursing Home Administrator will complete walking environmental rounds to identify any other areas of concern.
3. The maintenance and housekeeping staff will be re-educated on the policy for Clean, Safe and Orderly Environment by the Nursing Home Administrator/designee. The nursing staff will be educated on the facility policy for Clean, Safe and Orderly Environment by the Director of Nursing/designee. Guardian Angel rounds will be modified to include the shower rooms.
4. The Maintenance Director, the Housekeeping Director, Director of Nursing and the Nursing Home Administrator will complete walking environmental rounds weekly to ensure a clean, homelike environment is being maintained. These rounds will be ongoing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Observations:
Based on a review of vendor invoices, facility financial documents, and interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner.

Findings include:

Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized.

Review of vendor submitted communication dated 2/27/24, indicated that the Ambulance Vendor was no longer providing services to the company, and was owed $20,534.10.

During an interview on 3/1/24, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility no longer utilizes the services of the Ambulance Vendor, and provided alternative transportation with another vendor and the use of the facility transport van.

Review of the facility provided contractor report on 3/1/24, at approximately 2:00 p.m. revealed a balance of $30,843.62.

Review of Ambulance Vendor provided documentation on 3/4/24, indicated the most recent payment received was dated 10/18/23, and services to the facility terminated on 10/20/23.

During an interview on 3/4/24, at approximately 12:20 p.m. the Nursing Home Administrator confirmed that the facility failed to pay bills in a timely manner.

28 Pa. Code: 201.14(g) Responsibility of licensee.

28 Pa. Code: 201.18(e)(1)(2) Management.

Plan of Correction - To be completed: 03/19/2024

1. The facility bill for the Ambulance vendor is under dispute. A new Vendor, Ride4Health, is working with the facility to ensure no residents are affected by the bill dispute with Ambulance vendor.
2. A review of the facility's current transportation needs was conducted to determine if transportation needs were being met. Alternative vendors were engaged to ensure no items needed for the health and safety of residents in question would be at risk due to timeliness and accuracy of bills incurred. Facility also has acquired their own stretcher to be able to assist in transportation needs of the residents.
3. The facility will review the 24 hour report daily at stand up to ensure that residents transportation needs are addressed to ensure the Health and Safety of the Residents and any concerns will be addressed at that time.
4. The Nursing Home Administrator will conduct an audit of the transportation bill in question to ensure that any discrepancies with the Ambulance vendor are corrected and resubmitted to accounts payable. Concerns will be submitted to the facility Quality Assessment and Assurance Committee. Any concerns will be addressed as needed.

§ 205.33(a) LICENSURE Utility room.:

(a) Provisions shall be made in each nursing unit near the nurses ' station for utility rooms. The area shall have separate soiled and clean workrooms. The rooms may not be more than 120 feet from the most remote room served. If one nursing station services several resident corridors, a soiled utility room shall be on each unit.

Observations:
Based on observations and staff interview, it was determined that the facility failed to provide separate soiled and clean workrooms in two of two utility rooms (A/E-Wing utility room and B/C-Wing utility room), and failed to provide a soiled utility room shall be on each unit.

Findings include:

Review of "28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Utility room," dated 7/1/23, indicated the following subsection.

(a) Provisions shall be made in each nursing unit near the nurses' station for utility rooms. The
area shall have separate soiled and clean workrooms. The rooms may not be more than 120 feet
from the most remote room served. If one nursing station services several resident corridors, a
soiled utility room shall be on each unit.

During an observation on 3/1/24, at 1:15 p.m. of the A/E-Wing soiled utility room it was noted observed that a hopper (extra-large sluice sink with a spraying attachment) and a red, infections waste container with waste inside. Additionally, this room also contained a multitude of boxes of dressing change supplies, bottles of acetic acid, distilled water, bags of resident clothing, cleaning supplies, and maintance supplies.

During an interview on 3/1/24, at 1:20 p.m. Licensed Practical Nurse Employee E1 stated that the room is a utility room, used for both clean and dirty supplies.

During an observation on 3/1/24, at 2:35 p.m. of the B/C-Wing soiled utility room it was noted observed that a hopper with waste in it, and a red, infections waste container a multitude of sharps containers in it. Additionally, this room also contained a multitude of boxes of dressing change supplies, ostomy supplies, sterile urinary catheter kits, tube feeding formula, intravenous flushes, and insolation supplies.

Review of the facility provided building floor plan indicated that both of the above rooms identified were labeled as "Clean Utility." Review of the floor plan failed to reveal any rooms designated as a "Soiled Utility."

On 3/1/24 at 12:20 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the above observations.

On 3/4/24 at 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide separate soiled and clean workrooms in two of two utility rooms.

Plan of Correction - To be completed: 03/19/2024

1. The dressing supplies, bottles of acetic acid, distilled water, bags of resident clothing, cleaning supplies and maintenance supplies were removed from the A/E Wing soiled utility room. The hopper was cleaned in the A/E Wing soiled utility room. The red infectious waste container was removed and cleaned in the A/E Wing soiled utility room. The hopper on the B/C wing was cleaned. The red infections waste container was removed and cleaned in the B/C soiled utility room. The dressing supplies, ostomy supplies, sterile urinary catheter kits, the tube feeding formula, the intravenous flushes, and the isolation supplies were removed from the B/C soiled utility room.
2. The facility will provide a clean and a soiled utility room on A/E Wing and B/C wing.
3. Facility staff will re- educated on maintain a clean and a soiled utility room on A/E wing and B/C wing by the Nursing Home Administrator/designee.
4. The Nursing Home Administrator/designee will audit clean and soiled utility rounds during weekly walking rounds to ensure separate clean and soiled utility rooms are being maintained. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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