Spring Hill Rehabilitation And Nursing Center

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, clinical records and staff interview it was determined that the facility failed to provide ADL's (activities of daily living) for one of five residents reviewed (Resident Resident R5).Findings include: Review of facility policy Activities of Daily Living (ADL's) dated 9/22/25, indicated Care and services will be provided for the following activities of daily living bathing, dressing, grooming and oral care, toileting, transfer and ambulation, and eating to include meals and snacks. Resident Resident R5 was admitted to the facility on [DATE REDACTED].

Review of Resident Resident R5 admission information indicated diagnosis of liver cell carcinoma. Review o of Resident Resident R5 clinical record indicated hospice services-initiated referral due to needing additional care and services that could not be provided at home. Review of Resident Resident R2 clinical record documentation survey report for November 2025 indicated resident received care during the 11pm-7am shift on 11/20/25. Next documentation is a physician note at 1:23 p.m. in the afternoon. No information in the clinical record is noted for the resident getting bathed or eating assistance noted in the clinical record. Resident Resident R5 was sent out to the hospital on [DATE REDACTED] after sustaining a fall. During an interview on 12/23/25, at 12:00 p.m. the Director of Nursing (DON) and the Nursing Home NHA) confirmed that they could not locate other supportive documentation to show resident Resident R5 received ADL care and services during his stay at the facility. During an interview on 12/23/25, at 12:05 p.m. DON and NHA were informed that the facility failed to provide ADL care to Resident Resident R5. 28 Pa. Code 211.10 (d)Resident care policies.28 Pa.

Code211.12(c)(d)(1) Nursing services.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Review of the MDS dated [DATE REDACTED], indicated diagnosis of hyponatremia (condition that happens when the level of sodium in the blood is lower than the typical range), Parkinson's (is a movement disorder of the nervous system that worsens over time) and hyperlipidemia (high cholesterol - excess of lipids or fats in your blood). Review of the clinical record physician orders indicated the NA (sodium) levels weekly:Review of the November MAR on 11/26/25, failed to include an NA level.Review of the December MAR indicated

the following order:Send to ED due to emesis, BLE (bilateral lower extremities) edema (selling), BLE pain inability to obtain labs to monitor NA one time only for emesis, BLE edema, BLE pain - inability to obtain labs to mo for 1 Day -Start Date 12/12/2025 1145. Review of physician orders dated 9/11/25: indicated PLEASE FAX ALL LABS WEEKLY TO AHN NEPHROLOGY AT [PHONE NUMBER] one time a day every Wed. Review of the clinical record failed to indicate the lab work. During an interview on 12/23/25, at 3:00 p.m. Nursing Home Administrator and Director of Nursing confirmed that lab work was not completed for residents for approximately the last 4 weeks. Prior to this lab work was completed by a contractor who came in and into the facility and did the lab work. Lab work is something that the nursing facility usually provides to monitor residents' health conditions. During an interview the NHA and DON confirmed that the facility previously sent residents to dialysis and to drug and alcohol treatment programs and were unable to send residents directly to those programs. During an interview on 12/23/25, at 3 p.m. NHA and DON were informed that the facility failed to follow physician orders with doctor's appointments and lab work for four of five residents reviewed (Resident Resident R1, Resident R2, Resident R3, and Resident R4). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Based on review of facility documentation, staff and resident interview it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests payment for outstanding bills. Findings include: During an interview on 12/18/25, at 10:02 a.m. Nursing Home Administrator and Director of Nursing confirmed three residents had been sent of the facility to the hospital due to the facility not having transportation to get them to necessary physician appointments and medical appointments. NHA and DON stated that several transportation companies have been used throughout the year and the current transportation company indicated an outstanding bill. During an interview on 12/18/25, at 12:07 p.m.

Director of Nursing confirmed that the facility is unable to obtain labs on residents due to the laboratory company indicating an outstanding bill. Review of facility documentation AP Ledger 6/25 to 11/25 indicated

the following monies owed to the following companies:Access Corporation: $7802.34 - last payment 6/1/25Advantage Equipment: $ 2904.35 - last payment 6/1/25AEP Energy: $12,635.65 - last payment 7/31/25Affinity Health Services: $4084.63 - last payment 6/1/25Aflac WWHQ: $601.90 - last payment last payment 6/1/25All Scripts: $2247. - last payment 6/1/25Anthony Landscaping: $12,135 - last payment 10/28/25Cellone's Bakery: $410.46 - last payment 10/3/25Clipboard: $3629.70 - last payment 11/1/25Comcast: $1269.59 - last payment 10/13/25Duquesne Light: $4235.67 - last payment 10/15/25Ecolab: $664.88 - last payment 6/1/25Ehrlich: $343.44 - last payment 6/1/25Eshyft/shiftsstar LLC: $76,152.87 - last payment 8/20/25Excell Forces: $2204.80 - last payment 6/1/25FabStaffing Nursing: $1,116,194 - last payment 10/30/25Homeaides Inc.: $101,702.20 - last payment 10/15/25Integrated Medical Facilities: $76,727.96 - last payment 9/20/25Intellicompt: $8376.69 - last payment 10/17/25Klosterman Baking Comp-: $430.81 - last payment 6/1/25LabCorp: $9032.77- last payment 6/28/25Medic Rescues: $350 - last payment 10/3/25Pension strategies: $2030 - last payment last payment 6/1/25People's: $46,994.29 - last payment 10/19/25PharMerica: $613,420.90 - last payment 10/31/25Water company: $48,745.89 - last payment 10/13/25Point Click Care: $31,846.62 - last payment 9/1/25Steel Valley Ambulance: $4099 - last payment 6/1/25TwinMed LLC: $562,941.34 - last payment 11/20/25UPMC Health Plan: $50,288.58 - last payment 10/27/25 During an interview on 12/23/25, at 11:59 a.m. NHA and DON were informed that the facility failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests payment for outstanding bills. 28 Pa. Code 201.14 Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management.

Event ID:

Facility ID:

If continuation sheet