Manorcare Health Services-northside

F-F745.

28 Pa.Code: 211.16. (a) Social services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 46337 potential for actual harm Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was Residents Affected - Some determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarters (April 2024 through June 2024 and July 2024 through December 2024).

Findings include:

Review of facility policy Quality Assessment and Assurance Committee last reviewed 12/9/24, indicated the facility will maintain a QAA Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The committee will be composed of the following staff at a minimum.

-Director of Nursing

-Medical Director or his/her designees

-The Infection Preventionist

-At least three other facility staff members, one of which will be the Administrator, owner, a board member, or other individual in a leadership role.

The facility failed to have the QAPI Committee meeting sign-in sheets from the period of April 2024 through June 2024 available for review.

A review of the QAPI Committee meeting sign-in sheets from the period of July 2024 through December 2024, did not reveal that the Infection Preventionist was in attendance.

During an interview on 4/18/25, at 12:32 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49469 potential for actual harm Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed Residents Affected - Some to follow enhanced barrier precautions for two of five residents (Resident Resident R13 and Resident R68), failed to prevent cross contamination during a dressing change for one of three residents (Resident Resident R68), and failed to implement an infection control program that included a system of surveillance that included tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025).

Findings include:

Review of the facility policy Dressings, Dry/Clean, last reviewed 12/9/24, indicates the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure include but are not inclusive to:

-Clean bedside stand. Establish a clean field.

-Place the equipment on the clean field

-Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field

-Wash and dry hands

-Put on clean gloves

-Cleanse wound

-Discard items

-Remove gloves, wash and dry hands

-Apply the ordered dressing

-Remove gloves, wash and dry hands

-Clean bedside stand

-Wash and dry hands

Review of the facility policy Handwashing/Hand hygiene, last reviewed 12/9/24, indicates this facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0880 Review of facility policy Care and Treatment of Feeding tubes last reviewed 12/9/24, indicates to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent Level of Harm - Minimal harm or complication to the extent possible use infection control precautions and related techniques to minimize the potential for actual harm risk of contamination.

Residents Affected - Some Review of the facility policy Isolation-Categories of Transmission Based Precautions last reviewed 12/9/24, indicates enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug-resistant organism (MDROs). EBP's are in place for residents with wounds and indwelling medical devices. EBP's remain in place for the duration of the residents stay.

Review of Center for Disease (CDC) definition for Enhanced Barrier Precautions (EBP, a type of special isolation when providing direct care to a resident): The use of isolation gown and gloves during high-contact resident care activities including wound care.

Review of the facility policy Infection Prevention and Control Program last reviewed 12/9/24, indicates a system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections for all residents, staff, volunteers, visitors and other individuals providing service. COVID-19 Testing: Anyone with even mild symptoms of COVID 19 should receive a test as soon as possible. Testing is recommended typically on day 1, day 3, and day 5 (day of exposure is day 0). The facility will have a plan to investigate and manage how contact tracing will be performed.

Review of the facility policy Norovirus Prevention and Control, last reviewed 12/9/24, indicates the facility will implement strict infection control measures to prevent the transmission of the norovirus infection. Approaches for cohorting residents during the outbreak may include placing the resident in multi-occupancy rooms, or designated resident care areas or contiguous sections in the facility.

Review of the facility policy Outbreak of Communicable Disease last reviewed 12/9/24, indicates outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. The Infection Preventionist (IP) and Director of Nursing (DON) shall be responsible for including but not inclusive to:

Receiving surveillance information and tabulating data, maintaining a line list of identified cases and tracking.

Review of Resident Resident R13's clinical record indicates an admitted [DATE REDACTED].

Review of Resident 13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicates the diagnosis of heart failure (heart can't pump the way it should), hypertension (high blood pressure), and diabetes (high sugar in the blood)

Review of Resident Resident R13's physician orders dated 4/8/25, revealed the resident was ordered Enhanced Barrier Precautions (EBP).

Review of Resident Resident R13's physician orders dated 1/10/25, indicated Tylenol Extra Strength Oral Tablet 500 milligrams (MG) Give 2 tablet via G-Tube (a flexible tube placed into the stomach to deliver nutrition or medication) three times a day for pain/discomfort.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0880 During a medication administration observation completed on 4/15/25, at 1:10 p.m. Registered Nurse (RN) Employee E13 entered resident Resident R13's room. RN Employee E13 administered Resident Resident R13's Tylenol as Level of Harm - Minimal harm or ordered. RN employee E13 did not utilize a gown as indicated by EBP signage on the door. potential for actual harm

During an interview completed on 4/15/25 at 1:13 p.m. RN Employee E13 confirmed not utilizing a gown Residents Affected - Some during the medication administration via g-tube as required.

Review of Resident Resident R68's clinical record indicates an admitted [DATE REDACTED].

Review of Resident Resident R68's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/31/25, indicates the diagnosis of anemia (low iron in the blood), hypertension (high blood pressure) and diabetes (high sugar in the blood).

Review of Resident Resident R68's physician orders dated 3/26/25, indicates wound: cleanse left dorsal foot with Normal Saline Solution (NSS), pat dry, apply Medi honey to wound bed, apply oil emulsion dressing, cover with foam border dressing daily and as needed.

Review of Resident Resident R68's physician orders dated 4/6/25, indicate Enhanced Barrier precautions (EBP) related to due to wounds every shift.

During an observation on 4/17/25, at 11:05 a.m. RN Employee E31 entered Resident Resident R68's room to complete a dressing change. EBP signage was posted on the resident's door entrance. RN Employee E31 did not utilize a gown as indicated. RN Employee E31 placed the dressing supplies on the bed and applied gloves. Resident Resident R68 requested a pad/barrier to be placed under her foot. RN employee E31 did not bring a barrier into the room, Resident Resident R68 handed her a washcloth that was placed under her left foot. RN employee E31 the placed three paper towels on top of the washcloth and placed the heel of the left foot onto

the paper towels. RN Employee E31 removed the soiled dressing, placing it into her glove, used another glove as a waste bag and placed onto the bed. Observation of wound revealed a piece of oil emulsion remained on the top surface of the wound. Resident Resident R68 stated a package of the oil emulsion was in her bedside stand. RN Employee E31 retrieved the opened undated package and cut a small square, she removed her gloves and applied new gloves. RN Employee E31 placed the oil emulsion on top of the wound and applied the Medi honey on top of the oil emulsion by squeezing it directly from the tube, removed her gloves and placed new gloves prior to covering the area with a clean dressing. RN Employee E31 removed

the paper towels that were under Resident Resident R68's foot exited the room with the soiled supplies and placed all into the trash receptacle on the side of the treatment cart. She removed her gloves and indicated the treatment was completed.

During an interview completed on 4/17/25, at 11:26 a.m. RN Employee E31 confirmed not establishing a clean field prior to dressing change, numerous opportunities for hand hygiene were missed. Utilizing undated opened treatment supplies from the bedside stand, dispensing the Medi honey directly onto the wound from

the tube, utilizing a glove for her soiled discards and not following enhanced barrier precautions during the dressing change as required.

Review of the facility provided Gastrointestinal complaints/Norovirus time line on 4/17/25, indicated that in January of 2025, 27 residents were noted to have had GI complaints.

Review of the infection control tracking facility mapping for January 2025, did not include residents who were diagnosed with norovirus.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0880 During an interview completed on 4/17/25, at 1:56 p.m. Infection Preventionist (IP) RN Employee E18 confirmed that the residents who were diagnosed with the GI/norovirus in January of 2025, were not included Level of Harm - Minimal harm or on the infection control mapping. Upon further query IP RN Employee E18 also stated the facility has not potential for actual harm kept tract of the residents or employees with signs or symptoms of COVID 19. Upon asking IP RN Employee E18 the process for Covid testing if indicated, she stated we would complete a test if negative no further Residents Affected - Some testing would be needed, she was unable to provide information on testing guidelines and stated, we do what

the CDC says to do and further commented Trump took down all the stuff for the CDC guidance, it went away.

During an interview completed on 4/17/25, at 3:17 p.m. the Nursing Home Administrator confirmed that the facility failed to follow enhanced barrier precautions for two of five residents (Resident Resident R13 and Resident R68) failed to prevent cross contamination during a dressing change for one of three residents (Resident Resident R68) and failed to implement an infection control program that included a system of surveillance tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025).

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) (5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 49469

Residents Affected - Some Based on a review of select facility policy and staff interview, it was determined the facility failed to designate

a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25).

Findings included:

The Centers for Medicare and Medicaid Services regulation S483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location.

During an interview on 4/17/25, at 1:56 p.m., the IP, Employee E18 stated, I can't tell you an exact start date, I would say sometime in January they combined the wound care position with infection control, the other nurse handed it to the Director of Nursing around mid-October, my certificate date is 2/21/25.

During an interview on 4/17/25, at 3:17 p.m. the Nursing Home Administrator and Director of Nursing (DON) confirmed the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25).

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49469 potential for actual harm Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to Residents Affected - Few provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident Resident R13 and Resident R60).

Findings include:

Review of facility policy Influenza, Prevention and Control of Seasonal last reviewed 12/9/24, indicates this facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. All residents and staff are offered the vaccine prior to the onset of the influenza season.

Review of the facility policy Pneumococcal Vaccine last reviewed 12/9/24, indicates all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident had already been vaccinated.

Review of Resident Resident R13's clinical record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump the way it should) and chronic obstructive pulmonary disease (COPD-difficulty in breathing) MDS Section O- Special treatment, Procedures, and Programs O0250 indicated Influenza vaccine was coded 9- none of the above. O0300 indicated Pneumonia vaccine was coded a dash -.

During a review of Resident Resident R13's clinical record on 4/14/25, indicated that the Influenza and Pneumonia vaccination was not entered and was blank.

Review of Resident Resident R60's clinical record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident Resident R60's MDS dated [DATE REDACTED], indicated the diagnosis of anemia (low iron in the blood), coronary artery disease (CAD- buildup of plaque in the hearts arteries) and anxiety. MDS Section O- Special treatment, Procedures, and Programs O0250 indicated Influenza vaccine was coded 0- no reason 4-offered and declined. O0300 indicated Pneumonia vaccine was coded a 0- no reason 3-not offered.

During a review of Resident Resident R60's clinical record on 4/14/25, indicated that the Influenza and Pneumonia vaccination was not entered and was blank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0883 During an interview completed on 4/17/25, at 1:56 p.m. upon asking Infection Preventionist (IP) Employee E18 the facility procedure for the influenza vaccine she replied I did not participate in it Upon inquiry Level of Harm - Minimal harm or concerning pneumococcal vaccine IP Employee E18 stated we don't try to get every immunization they potential for actual harm missed further query concerning the immunizations for residents in the facility, IP Employee E18 replied we don ' t really have a process, we don ' t document of the refusal for immunizations and confirmed that the Residents Affected - Few facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident 13 and Resident R60).

28 Pa. Code 211.5(f) Clinical records

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

28 Pa. Code 211.12(d)(1)(3) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 45577 potential for actual harm Based on observations and staff interviews, it was determined that the facility failed to make certain that Residents Affected - Few equipment was in safe operating condition in the main kitchen and the facility failed to maintain essential equipment with a dryer not working ( 1 of 2 dryers).

Findings include:

Review of Code of Federal Regulations S483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

During an observation on 4/17/25, at 12:35 p.m., it was revealed that the main kitchens six well steam table (a type of commercial food service equipment that is used to keep foods at optimal serving temperatures) was operating with only three steam wells.

During an interview on 4/17/25, at 1:32 p.m., Dietary Manager (DM) Employee E11 confirmed that only three of six steam table wells are functioning time of interview. Further interview revealed that DM Employee E11 was hired in December 2024, and at that time, 2 steam wells were broke and not functioning. DM Employee E11 stated that the third steam well just broke within the last few weeks.

During an interview on 4/17/25, at 1:35 p.m., Dietary [NAME] Employee E12 revealed that he was hired nine months ago, and at that time 2 steam wells were broken and not functioning. Employee E12 stated that the third steam well just broke within the last month, and that back in October 2024, Maintenance was made aware of malfunctioning steam table, and service call from an outside food service equipment repair vendor was completed. Employee E12 stated that the vendor identified equipment parts needed to be ordered and replaced in order to fix the 2 broken wells.

During an interview on 4/17/25, at 2:30 p.m., Maintenance Director (MD) Employee E13 confirmed that an outside food service equipment vendor came in and looked at the broken steam table wells in October 2024, and provided the facility with an invoice identifying parts needed and cost to repair. MD Employee E13 stated that this invoice for repair was provided to administration for payment.

During an interview on 4/18/25, at 11:45 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to make certain that equipment was in safe operating condition in the main kitchen.

During an observation on 4/16/25, at 11:31 a.m. one dryer was not working and the other dryer was in use in

the laundry room.

During an interview on 4/16/25, at 11:35 a.m. Laundry Assistant Employee E34 Stated the dryer is down, so

we only have one dryer.

During an interview on 4/17/25, 10:10 a.m. Director of Maintenance Employee E16 confirmed that the facility has a dryer down and the facility failed to maintain essential equipment.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 395666 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395666 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212

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)

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 35785

Residents Affected - Few Based on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Physical Therapist Employee E3).

Findings include:

The facility Abuse, neglect, and misappropriation education policy reviewed 12/9/24, indicated to abuse, neglect, and misappropriation of resident funds education is completed upon hire and at least annually for all employees.

Review of Physical Therapist Employee E3 personnel record indicated she was hired on 3/31/25. Facility punch detail report (Report indicating which days staff worked) dated 4/17/25, indicated that Physical Therapist Employee E3 worked at the facility for five days in April of 2025.

Review of Physical Therapist Employee E3 personnel record did not include abuse training during her orientation to the facility.

During an interview on 4/17/25, at 12:34 p.m. the Human Resources Employee E5 confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for Physical Therapist Employee E3 as required.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 395666