Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Hills Post Acute during CMS and state inspections, most recent first.
Incomplete and non-resident-specific care plans for fall risk and functional needs. Four residents had care plans that did not reflect their specific needs or include measurable, individualized interventions such as toileting schedules, monitoring, or fall mats. The records showed repeated falls, including falls from bed, in the bathroom, and while reaching for items or trying to toilet independently, while the DON and NHA reviewed the plans and stated they had been updated even though they were not resident-specific and did not include needed interventions.
A resident with severe cognitive impairment, fall risk, and impulsive behavior to get out of bed had two falls after being found incontinent and on the floor or falling out of bed. The care plan called for reminders to use the call bell, staff anticipation of needs, low bed position, and supervised view as much as possible, but the incident documentation did not show that these needs were consistently addressed. The NHA and DON confirmed the facility failed to ensure adequate supervision and assistance to prevent accidents.
Failure to Provide NOMNCs for Two Residents: The facility did not provide NOMNCs for two residents when Medicare Part A coverage was ending. Records showed one resident elected discharge home and another had discharge plans changed from one day to the next, but the chart lacked signed NOMNCs showing the residents were informed of the appeal process and potential non-coverage of services.
Two dietary aides were observed working in the kitchen without required beard restraints, contrary to facility policy that mandates hair restraints for food service staff with facial hair. The Dietary Manager confirmed that beard restraints should have been used.
Multiple residents reported that staff frequently left soiled linen hampers open in hallways, causing strong odors to fill the area and enter resident rooms. Residents often had to close the hampers themselves and move them away from their rooms. These issues were documented in facility records and discussed with the DON, but staff compliance was inconsistent. Observations confirmed strong urine odors and the presence of soiled linen carts near resident beds. The facility administrator acknowledged the failure to maintain a clean and homelike environment.
The facility did not provide required written bed-hold policy notifications to residents or their representatives at the time of hospital transfer for several individuals with complex medical conditions, as confirmed by record review and staff interviews. Documentation of these notifications was missing in multiple cases involving transfers for acute medical issues.
Direct care staff were not made aware of physician-ordered fluid restrictions for three residents with complex medical needs, resulting in multiple instances where fluid intake exceeded prescribed limits. Staff interviews and documentation reviews revealed a lack of communication and monitoring, with the DON and administrator confirming the failure to ensure staff awareness of these critical orders.
Two residents with cardiac conditions received Coreg despite vital signs that did not meet physician-ordered parameters, including low blood pressure and low heart rate. Facility policy and care plans required medications to be administered according to prescriber orders, but these were not followed on multiple occasions, as confirmed by the facility's administration.
The facility did not post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program on any of its nursing units, omitting required address and email details and failing to make this information accessible and understandable to residents or their representatives.
Postings indicating the location of the Department of Health's most recent survey results were not accessible to residents and visitors on all nursing units. This was confirmed by the Nursing Home Administrator, who acknowledged the absence of these required postings.
Required written information on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs was not displayed on any of the facility's nursing units. This was confirmed by observation and staff interview.
South Hills Post Acute failed to provide prompt assistance to residents, compromising their dignity and quality of life. Multiple residents reported extended waits for care, with staff turning off call lights and delaying assistance. The facility's policy on resident rights was not followed, as confirmed by the Nursing Home Administrator and DON.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with toileting hygiene for several residents. Residents reported waiting from half an hour to several hours for help, often being left in soiled conditions. Interviews with the Nursing Home Administrator and DON confirmed the staffing inadequacies impacting resident care.
The facility failed to provide adequate supervision for a resident with a history of opioid dependence and alcohol use, leading to an overdose. Despite being alert and oriented, the resident was not care planned for his dependencies. The resident was found slumped over in a taxi, with heroin in his possession, and was administered Narcan with minimal outcome before being transported to the hospital.
The facility failed to establish baseline care plans within 48 hours for three residents admitted with various medical conditions, including diabetes, high blood pressure, colon cancer, obstructive and reflux uropathy, and panlobular emphysema. The Director of Nursing confirmed the oversight.
The facility failed to provide prescribed treatment and services for pressure ulcers for three residents. One resident with coronary artery disease and hemiplegia was not repositioned as required, leading to worsening ulcers. Another resident with dementia developed a Stage 4 ulcer that was not documented until it worsened, and wound care was inconsistently documented. A third resident with COPD and diabetes did not receive prescribed offloading boots, resulting in a new pressure ulcer. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to ensure that pneumococcal immunizations were offered to two residents as required by their policy and CDC guidelines. One resident with chronic osteomyelitis, high blood pressure, and chronic kidney disease, and another with coronary artery disease, hemiplegia, and a history of stroke, were not offered the vaccine, and there was no documentation of education provided about the vaccination.
The facility failed to ensure proper storage and disposal of medications in one medication room and two medication carts. Expired medications and improperly dated insulin vials were found, and a medication cart was left unlocked and unattended. Staff confirmed these deficiencies during interviews.
The facility failed to ensure adequate supervision and assistance for a resident, resulting in a fall and injury. The resident, who required a one-person assist with ADLs, fell out of bed and sustained a laceration due to improper handling by a CNA. Interviews confirmed the failure to follow proper procedure.
Incomplete and Non-Resident-Specific Care Plans for Fall Risk and Functional Needs
Penalty
Summary
The facility failed to ensure that four residents had updated, person-centered care plans that were individualized to their specific needs and reflected current standards of practice. The facility policy stated that each resident should have a comprehensive care plan developed within 7 days of the comprehensive assessment, with measurable objectives and timetables addressing physical, psychosocial, and functional needs. Review of records and staff interview showed that the care plans for Resident R90, Resident R70, Resident R21, and CR304 were not resident-specific and did not include interventions matched to their identified problems. Resident R90 had diagnoses including fractured ribs after a fall, stroke affecting the non-dominant side, MI, dysrhythmia, HF, and malnutrition, and had severe cognitive impairment on a BIMS. His care plan identified impulsive behavior and fall risk, with interventions to remind him to call for help and keep the call bell in reach, but no interventions for fall mats, monitoring, or other anticipated needs. He had a fall on 5/3/26 when he was incontinent and found on the floor, was sent to the hospital because the fall was unwitnessed and head injury could not be ruled out, and then had another fall on 5/9/26 when he fell out of bed, was incontinent, and had a head laceration. The incident report did not indicate whether the bed was in low position or whether he had been toileted prior, despite the plan calling for staff to anticipate his needs. Resident R70 had diagnoses including heart arrhythmia, falls, cognitive communication deficit, enlarged prostate, and dizziness. His care plan identified fall risk and included staff anticipating needs, telling him to call for assistance, and helping with opening his door, but it did not include toileting, monitoring, fall mats, or similar interventions. He fell in the bathroom while toileting himself, fell out of bed while trying to get to the bathroom and was incontinent, fell while attempting to get into bed for a nap, and later fell again in the bathroom while attempting to toilet himself. Resident R21 had diagnoses including heart arrhythmia with pacemaker, muscle disorder, insomnia, anxiety, and pulmonary emboli. Her care plan also identified fall risk and included anticipating needs, calling for assistance, and keeping items within reach, but did not include toileting, monitoring, or fall mats. She fell out of her recliner while reaching for lotion that was not within reach and later fell in the bathroom while toileting herself. CR304 had diagnoses including heart arrhythmia, falls, kidney disease, spinal stenosis, and obesity. Her care plan identified risk for ADL decline and need for one-person assistance with bed mobility and transfers, but only included asking for help. She slid out of bed onto the floor and later had a witnessed fall while standing at bedside alone and trying to get to the toilet, with no care plan changes documented.
Failure to Provide Adequate Supervision and Assistance to Prevent Falls
Penalty
Summary
The facility failed to ensure that one resident received adequate supervision and assistance to prevent accidents. Resident R90 was admitted with diagnoses including fractured ribs after a fall, stroke affecting the non-dominant side, myocardial infarction, heart dysrhythmia, heart failure, and malnutrition. The resident had severe cognitive impairment on a Brief Interview for Mental Status, and the admission fall risk assessment identified the resident as a moderate fall risk. The care plan noted impulsive behavior to get out of bed and identified the resident as at risk for falls, with interventions to remind the resident to call for help, keep the call bell in reach, and anticipate needs for assistance. Despite these identified needs, Resident R90 experienced two falls. On 5/3/26, the resident was incontinent and found on the floor by a nurse aide, and was sent to the hospital because the fall was unwitnessed and a head injury could not be ruled out. A subsequent plan of care directed that the bed be kept in low position, personal items be within reach, and the resident be in supervised view as much as possible. On 5/9/26, the resident fell out of bed and was incontinent again; the incident report did not indicate whether the bed was in low position or whether staff had toileted the resident beforehand, despite the plan of care identifying anticipated needs for assistance. The Nursing Home Administrator and DON confirmed the facility failed to make certain the resident received adequate supervision and assistance to prevent accidents.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for two residents, R302 and R303, when their Medicare Part A covered services were ending. Review of the NOMNC instructions showed that an advanced copy must be given no later than two days before termination of services, and the facility’s own NOMNC form stated that the resident has a right to appeal non-payment of services and must request an appeal by noon of the day before the effective date of non-coverage. For Resident R302, the clinical record showed admission to the facility and that the last covered day of Part A service was 1/23/26. A progress note on 1/23/26 at 12:53 p.m. documented that the patient was electing discharge to home that day via family, but the record did not show a NOMNC was given or signed. For Resident R303, the record showed admission to the facility and that the last covered day of Part A service was 4/8/26. Progress notes documented an initial plan to discharge home on 4/7/26, then a change to discharge home on 4/8/26, and a physician order dated 4/6/26 indicated discharge to home on 4/8/26 with home health. During interview, the NHA confirmed the facility was unable to provide NOMNC forms for either resident.
Failure to Ensure Proper Use of Beard Restraints in Kitchen
Penalty
Summary
The facility failed to ensure that food service staff properly restrained facial hair while working in the Main Kitchen. During an observation, a dietary aide and a volunteer dietary aide were seen in the kitchen without beard restraints, despite the facility's policy requiring hair restraints to prevent hair from contacting food. The Dietary Manager confirmed that staff with facial hair are required to wear beard restraints, but this was not followed during the observed period.
Failure to Maintain a Clean and Homelike Environment Due to Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six of fourteen residents on the second and third floors. Residents reported that staff rarely closed hampers containing soiled linen, resulting in strong odors of soiled linen and urine permeating the hallways and entering residents' rooms. Residents stated they often had to close the hampers themselves and move them away from their rooms. These concerns were documented in the facility's Concern Log and Resident Council Minutes, and residents indicated that the issue was discussed multiple times with the Director of Nursing, but staff compliance was only temporary before the problem recurred. Observations confirmed the presence of strong urine odors on the third-floor nursing unit and a soiled linen cart was found next to a resident's bed. The Nursing Home Administrator acknowledged the facility's failure to maintain a clean and homelike environment for the affected residents on two of the three nursing units. The deficiency was substantiated by resident interviews, facility records, and direct observation.
Failure to Provide Bed-Hold Policy Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital for five of six residents reviewed. Federal regulation S483.15(d) requires that residents receive written information about bed-hold policies both prior to and upon transfer, with documentation of attempts to notify representatives if direct notification is not possible. The facility's own policy also states that this information should be provided upon admission, transfer, or therapeutic leave, and if any changes occur to the policy. Clinical record reviews for multiple residents revealed that, despite being transferred to the hospital for various acute medical needs—including exacerbation of UTI symptoms, abnormal vital signs, fever, chest pain, and complications related to dialysis—there was no documentation that the required written bed-hold notification was given at the time of transfer. This deficiency was identified for residents with significant medical histories, such as coronary artery disease, diabetes, stroke, heart failure, seizure disorder, cardiomyopathy, chronic kidney disease, pneumonia, atrial fibrillation, hemiplegia, and malnutrition. During staff interviews, both the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not ensure the provision of written bed-hold policy notices to residents or their representatives at the time of hospital transfer. This failure was observed across multiple instances and residents, as evidenced by the absence of documentation in the clinical records reviewed.
Failure to Communicate and Enforce Fluid Restrictions for Residents
Penalty
Summary
The facility failed to ensure that direct care staff were aware of and adhered to physician-ordered fluid restrictions for three residents with significant medical conditions, including cardiomyopathy, chronic kidney disease, cerebral palsy, hyponatremia, coronary artery disease, and schizophrenia. Despite clear physician orders and care plans specifying daily fluid restrictions for these residents, staff interviews revealed that nurse aides were not informed of these restrictions. Observations showed that residents had access to large cups of ice water at their bedsides, and care records indicated multiple instances where fluid intake exceeded the prescribed limits. In some cases, the Kardex and nurse aide census sheets did not include information about the fluid restrictions, further contributing to the lack of staff awareness. Additionally, documentation for at least one resident failed to show any monitoring of fluid intake, and staff interviews confirmed a general lack of knowledge regarding which residents were on fluid restrictions. The Director of Nursing and the Nursing Home Administrator acknowledged that fluid restriction orders should have been communicated to staff and confirmed the failure to do so. These lapses resulted in the facility not maintaining acceptable parameters of nutritional status for the affected residents, as required by facility policy and state regulations.
Failure to Prevent Significant Medication Errors Related to Coreg Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of Coreg (carvedilol) to two residents despite vital signs that did not meet the parameters set by physician orders. Facility policy required medications to be administered in accordance with prescriber orders, which for these residents included holding Coreg if systolic blood pressure (SBP) was less than 110 mmHg or if heart rate was less than 60 beats per minute. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, the physician order specified to hold Coreg for SBP less than 110 or heart rate less than 60. However, review of the medication administration records showed that Coreg was administered multiple times when the resident's SBP was below 110, with readings as low as 89. The resident's care plan also indicated that medications should be administered per physician order, but this was not followed on several occasions. Another resident with coronary artery disease, diabetes, and hypertension had a physician order to hold Coreg for heart rates less than 60. Despite this, the medication was administered repeatedly when the resident's heart rate was below 60, with documented rates as low as 48 beats per minute. The care plan for this resident also required medication administration per physician order, but this was not adhered to. The Nursing Home Administrator and DON confirmed these findings during an interview.
Incomplete Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program on all three nursing units, as required by regulation. Observations conducted on the First Floor, Second Floor, and Third Floor nursing units revealed that the posted information was missing the address and email contact details for both agencies. This information was not made available in a form and manner that was accessible and understandable to residents or their representatives. The Nursing Home Administrator confirmed during an interview that the required contact information was not fully posted on any of the nursing units.
Survey Results Location Not Posted
Penalty
Summary
The facility failed to ensure that postings identifying the location of the Department of Health's most recent survey results were readily accessible to residents and visitors on all three nursing units. During an observation, no such postings were found in the facility. This was confirmed by the Nursing Home Administrator, who acknowledged that the required postings were not present in any of the three nursing unit locations.
Failure to Display Medicare and Medicaid Information on Nursing Units
Penalty
Summary
The facility failed to display written information regarding the application process for Medicare and Medicaid benefits, as well as information on receiving refunds for previous payments covered by these programs, on all three nursing units (First Floor, Second Floor, and Third Floor). This deficiency was identified during observations conducted on each unit, where the required information was not present. The Nursing Home Administrator confirmed during an interview that the facility did not have the mandated written information displayed on any of the nursing units, as required by state regulations.
Failure to Provide Prompt Assistance and Maintain Resident Dignity
Penalty
Summary
South Hills Post Acute was found to be non-compliant with federal and state regulations regarding resident rights and dignity. The facility failed to provide prompt assistance to meet the care needs of five residents, as evidenced by resident interviews and clinical record reviews. The facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to, resulting in residents experiencing delays in receiving necessary care. Resident R1 reported being left in soiled conditions for several hours despite using the call bell multiple times. Staff reportedly turned off the call light and dismissed the resident's requests for assistance. Similarly, Resident R2 experienced delays in receiving care, with staff turning off the call light and leaving the resident waiting for extended periods. Resident R3, who was dependent on assistance due to a broken hip, also reported long waits for care, with staff citing breaks as a reason for the delay. Residents R4 and R5 shared similar experiences of waiting for assistance, with staff turning off call lights and delaying care. These incidents were confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to provide an environment that promotes dignity and quality of life for the residents involved.
Plan Of Correction
Social services met with resident R1, R2, R3, R4, and R5 to ensure the care provided to these residents since initial discovery was completed with respect, kindness, and dignity. A complete floor audit was completed by DON and/or designee to ensure there was no skin breakdown, emotional distress, and no further issues identified since initial discovery indicating lack of respect, kindness, and dignity. All staff was given Resident rights education by the staff educator to ensure understanding of resident rights covering prompt care, incontinence needs, and call bell response. The administrative team and/or designee will complete guardian angel rounds on the unit 2x a week for 2 weeks to ensure all residents are treated with respect, kindness, and dignity. Guardian Rounds audits will be reviewed by Administrator and/or designee at the monthly QAPI meeting to ensure citation has been cleared. Date of Corrective action: 4/24/2025
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the care needs of five residents, as evidenced by multiple instances of delayed response to call lights and inadequate assistance with toileting hygiene. The facility's policy on answering call lights, which requires staff to promptly respond to residents' requests and provide necessary assistance, was not adhered to. This resulted in residents being left in soiled conditions for extended periods, ranging from half an hour to several hours. Resident R1 reported being left in a soiled brief from 6 p.m. to 2 a.m. over a weekend, despite using the call bell multiple times. Staff reportedly turned off the call light without providing assistance, indicating they would return later. Similarly, Resident R2 experienced delays in receiving help for toileting hygiene, with waits ranging from half an hour to two hours. Resident R3, who has a broken hip and is dependent on staff for toileting, reported waiting up to three and a half hours for assistance, with staff citing breaks as a reason for the delay. Resident R4, who requires substantial assistance for toileting, also experienced delays, having to wait over an hour on occasion. Resident R5 reported similar issues, with waits exceeding half an hour. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to provide sufficient staffing to meet the residents' needs, impacting the quality of care for these individuals.
Plan Of Correction
F 0725 Sufficient Nursing Staff The facility failed to ensure sufficient staffing to meet residents' care needs for five of fifteen residents who require care (Residents R1, R2, R3, R4 and R5). What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Social Services met with residents R1, R2, R3, R4 and R5 to discuss the identified situation and ensure all care needs were met in a timely manner. Daily staffing meetings will be held with scheduler, DON and Admin and/or designee to ensure sufficient staffing is provided for all 3 shifts and meeting the staffing ratio and PPD. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The staff educator provided education to all staff on prompt response for "Answering call Lights." Daily Huddles will occur with administrative staff and/or designee with all floor staff to communicate necessary needs expressed by residents during guardian rounds. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? Daily Huddles will be initiated to ensure all staff is informed of residents' needs and staffing will be reviewed as well as assignments given to ensure all residents receive timely care. The DON and/or designee will complete an audit 2x a week with 5 residents for two weeks to ensure all residents have received prompt care and in a timely manner, as well as complete staffing tool to ensure facility is meeting ratio and PPD. How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? All audit findings will be reviewed by DON and/or designee at the monthly Quality Assurance Meeting to determine if deficient practice has been corrected or will need to continue by DON and/or designee. Dates of when the corrective action will be completed: April 24th, 2025.
Failure to Provide Adequate Supervision Resulting in Resident Overdose
Penalty
Summary
The facility failed to provide adequate supervision for Resident R1, who had a history of opioid dependence and alcohol use. Despite being alert and oriented, and able to make his own decisions, Resident R1 was not care planned for his opioid and alcohol dependence. On the evening of 5/9/24, a taxi service brought Resident R1 back to the facility, finding him slumped over in the back seat and appearing to be under the influence. Emergency services were called, and the police found a bag of heroin on Resident R1. Medics administered Narcan with minimal outcome, and Resident R1 was transported to the hospital. Interviews with the Director of Nursing (DON), Nurse E1, and the Nursing Home Administrator (NHA) confirmed the incident and acknowledged the facility's failure to provide adequate supervision. The facility's policy on Opioid Use Disorder, which mandates assessing patients for the risk of opioid use disorder and implementing appropriate interventions, was not followed for Resident R1. This lack of supervision and failure to implement the necessary care plan led to Resident R1's overdose.
Failure to Establish Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to establish a baseline care plan within 48 hours of admission or readmission for three residents. Resident R301, who was admitted with diagnoses including diabetes, high blood pressure, and colon cancer, did not have a baseline care plan for his colostomy. Resident R307, admitted with high blood pressure, obstructive and reflux uropathy, and a fracture of the right lower leg, did not have a baseline care plan for catheter care. Resident R312, admitted with high blood pressure, diabetes, and panlobular emphysema, did not have a baseline care plan for supplemental oxygen via nasal cannula. The Director of Nursing confirmed that the baseline care plans for these residents were not initiated within the required 48-hour timeframe. The facility's policy mandates the development and implementation of a baseline person-centered care plan within 48 hours of admission or readmission, but this was not adhered to for the three residents mentioned. The lack of timely baseline care plans was identified through clinical record reviews and staff interviews.
Failure to Provide Prescribed Pressure Ulcer Care
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of pressure ulcers for three residents. Resident R22, who had a history of coronary artery disease, hemiplegia, and stroke, was at high risk for pressure ulcer development. Despite physician orders and care plans indicating the need for turning and repositioning every two hours, observations revealed that Resident R22 was consistently positioned on their back, leading to the deterioration of existing pressure ulcers and the development of new ones. The Nursing Home Administrator confirmed that Resident R22 was not turned and repositioned appropriately during the observations. Resident R76, diagnosed with dementia and traumatic brain injury, also experienced a failure in pressure ulcer care. The resident developed a new Stage 4 pressure ulcer on the left ankle, which was not documented until it had significantly worsened. Observations showed that Resident R76 was not turned and repositioned as required, and there were multiple days where wound care was not documented as completed. The Nursing Home Administrator confirmed the development of a facility-acquired pressure ulcer and the lack of appropriate repositioning and wound care documentation. Resident R85, with diagnoses of COPD and diabetes, was admitted with existing pressure ulcers and was at high risk for developing new ones. Despite care plans and orders for offloading boots, observations indicated that Resident R85's heels were not offloaded, and the resident was not wearing the prescribed offloading boots. The Nursing Home Administrator confirmed that Resident R85 developed a facility-acquired pressure ulcer and was not turned and repositioned appropriately during the observations. The facility failed to provide the necessary treatment and services for pressure ulcer care for these residents.
Failure to Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered to two of five residents, as required by their policy and CDC guidelines. Resident R101, who was admitted on [DATE], had diagnoses including chronic osteomyelitis, high blood pressure, and chronic kidney disease. The Minimum Data Set (MDS) dated 3/28/24 indicated that Resident R101 was not offered the pneumonia vaccine, and there was no documentation of education provided to the resident or their representative about the risks and benefits of the vaccination. Similarly, Resident R119, admitted on [DATE], had diagnoses of coronary artery disease, hemiplegia, and a history of stroke. The MDS dated [DATE] also indicated that Resident R119 was not offered the pneumonia vaccine, and there was no documentation in the clinical record of the resident being offered the vaccination. During an interview, the Nursing Home Administrator confirmed the facility's failure to offer the pneumococcal immunization to these residents.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure that medications and medication supplies were properly stored and/or disposed of in one of three medication rooms and two of seven medication carts. Specifically, in the Second-floor medication room, a bottle of prescription barrier lotion for a resident was found with an expired use-by date, and multiple vacutainers were found to be expired. Additionally, a medication cart on the second floor was observed to be unlocked and unattended, and several insulin vials and injectable pens were found to be improperly dated or undated. During interviews, staff confirmed the presence of expired and improperly stored medications. The Nursing Home Administrator acknowledged that the facility did not comply with its policy on the storage and expiration dating of medications and biologicals. The deficiencies were observed during a survey, and the facility's failure to adhere to proper medication storage and disposal protocols was confirmed by multiple staff members.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for Resident R1. Resident R1, who was admitted with diagnoses including pneumonia, bladder dysfunction, and seizure disorder, required a one-person assist with all activities of daily living (ADLs). During care, CNA Employee E1 rolled Resident R1 away from them, resulting in the resident falling out of bed and sustaining a three-centimeter laceration to the left forehead. The CNA had received training on resident turning and positioning, body alignment, and moving in bed but failed to follow proper procedure during the incident. Interviews with the CNA, Resident R1, the Director of Nursing (DON), and the Nursing Home Administrator confirmed the failure to follow proper procedure. The CNA was confused about the details of the incident and could not recall how it happened. The DON and the Nursing Home Administrator acknowledged that the facility did not provide adequate supervision and assistance to prevent the accident, leading to Resident R1's fall and injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bethel Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 1.1 mi | ★★★★★ | 21 | 0 |
| Concordia Of The South Hills | 2.2 mi | ★★★★★ | 0 | 0 |
| Asbury Health Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Whitehall Borough Post Acute | 2.6 mi | ★★★★★ | 8 | 1 |
| John J Kane Regional Center-sc | 2.7 mi | ★★★★★ | 4 | 0 |
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