Deficiency Index

Concordia of the South Hills

Pittsburgh, Pennsylvania · CCN 396089

15 surveys since 2011. The first finding at harm level was recorded in 2019.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
48
Surveys
15
Harm or worse
1
Immediate jeopardy
0
The record, 2011–2025
’11’15’20’25
No harm recordedHarm or worseNot surveyed
Harm or worse1

Findings where a surveyor recorded actual harm to a resident.

Beyond CMS’s monthly file13/15

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
46
Ownership
Non profit - Corporation
Chain
CONCORDIA LUTHERAN MINISTRIES
County
Allegheny
Medicare-certified since
2004

CMS ratings

Overall
5
Health inspection
5
Staffing
5
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=13, floor 20).

Last survey on record

Apr 4, 2025

584 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.554.80
Registered-nurse hours per resident day1.22—
Annual nurse turnover37.5%31.9%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD375.0%E125.0%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 4 of the 48 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6842×

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • F6861×

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • F7611×

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

In the surveyor’s words

From the most serious findings on record at Concordia of the South Hills, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF761Apr 18, 2024

    Based on review of manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (First-floor medication room) and one of one medication carts (First-floor medication cart). The facility failed to make certain medication rooms were secured for one of two medication rooms (Second Floor Medication room). Findings include: Review of the facility policy Medication Storage dated [DATE], indicated the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. […]

  • No harm, potential for more than minimal, patternF679May 27, 2022

    Based on review of facility documents, activity calendars, observations, and resident and staff interviews, it was determined that the facility failed to meet the activity needs for five of five confidential group residents (R300, R301, R302, R303, and R304) and 11 of 18 residents (Residents R4, R5, R7, R13, R21, R26, R31, R139, R140, R141, and R142). Findings include: A review of the facility's Skilled Nursing/Rehab Facility Handbook: Recreational Activities indicated Our Activity Department plans daily group and individual activities for you, with consideration given to your interest and your functional abilities. You can request assistance to get to and from activities if needed. […]

  • No harm, potential for more than minimal, isolatedF684Apr 4, 2025

    Based on review of clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for two of seven residents reviewed (Residents R1, and R12) Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. […]

  • No harm, potential for more than minimal, isolatedF684Apr 18, 2024

    Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess residents for hypoglycemia (low blood glucose), failed to document and/or institute interventions for hypoglycemia, and failed to document notification to physicians of decreased capillary blood glucose (CBG) levels for one of three residents (Residents R154). Findings include: Review of the facility Hypoglycemia Protocol dated 8/3/23, indicated for conscious persons with a CBG level: - less than 45 mg/dl (milligrams per deciliter), to give 30 g (grams) of carbohydrates (8 ounces of juice or soda or 2 tablespoons jelly or sugar). Repeat CBG level in 15 minutes. […]

  • No harm, potential for more than minimal, isolatedF686Apr 18, 2024

    Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of three residents (Resident R7). Findings include: Review of the facility policy Pressure Ulcer Protocol dated 8/3/23, indicated the facility will provide a program of prevention, care, and treatment of pressure ulcers to all residents to prevent skin breakdown and to promote healing. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. […]

Read 20 findings in full →The most serious and the most recent: 20 of 48 on record.

Every survey on record

FindingsAt actual harm or above

  • Apr 4, 2025Standard1 finding
  • Apr 18, 2024Standard3 findings
  • May 16, 2023Standard and complaint3 findings
  • May 27, 2022Standard2 findings
  • Mar 29, 2022Complaint1 finding
  • Mar 18, 2021Standard3 findings
  • Jan 16, 2020Standard3 findings
  • Sep 18, 2019Complaint1 finding · 1 harm
Show the 7 earlier surveys
  • Dec 19, 2018Standard8 findings
  • Jan 20, 2017Standard2 findings
  • Dec 9, 2015Standard1 finding
  • Oct 13, 2015Complaint1 finding
  • Dec 5, 2013—12 findings
  • Jan 18, 2013—4 findings
  • Dec 7, 2011—3 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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