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

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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 revisit survey completed on February 5, 2024, it was determined that South Hills Rehabilitation and Wellness Center corrected the deficiency identified during the survey of December 28, 2023, as related to the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities however, has continued non-compliance as related to the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nursing assistant per 12 residents during the evening shift on one of six days (1/27/24).

Findings include:

A review of the facility census and nursing hours data from 1/23/24 through 1/28/24 revealed the following nursing assistant staffing shortage:

Evening shift:

1/27/24census 67actual hours 39.50required hours 41.88.

During an interview on 2/5/24, at 3:10 p.m. the Nursing Home Administrator confirmed the facility administrative staff failed to provide the required minimum nurse aide ratios on the above listed date.



 Plan of Correction - To be completed: 02/13/2024

1. The facility cannot correct that the nurse aide ratio staffing ratio was not meet on 1/27/24. There were no adverse effects to residents on the identified date.
2. The facility will ensure that staffing ratios are met every shift.
3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are meet each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff to assist. Nursing Administration will call the facility on off shifts and weekends to ensure staffing ratios are being met.
4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.


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