South Hills Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Aug 11, 2025

  Based on observation, interview, and record review it was determined the facility failed to implement infection control practices to prevent the spread of clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon) for all residents, staff, and visitors for 1 of 1 sampled resident (#78). This failure, determined to be an Immediate Jeopardy situation, placed all residents, staff, and visitors at risk for exposure to c-diff, which is highly contagious and can cause serious illness, including life-threatening colitis and death. Findings include:The online reference CDC Preventing C-Diff. […]

• Immediate jeopardy, isolatedF744Jul 15, 2026

  Based on observation, interview and record review it was determined the facility failed to assess, develop, reassess and implement a person-centered care plan for dementia care needs to ensure resident safety for 4 of 4 sampled residents (#s 1, 2, 3, and 4) reviewed for elopement. As a result, Resident 1 left the faciity on [DATE] without staff knowledge, had an incident involving her/his power wheelchair getting stuck outside on [DATE], and on [DATE] left the facility again, which placed the resident at risk for serious injury. Resident 1 lacked a comprehensive assessment and person-centered care plan for her/his dementia with Lewy bodies. There were no interventions developed and implemented to ensure the appropriate supervision and monitoring were in place to prevent an injury. […]

• Actual harm, isolatedF684Feb 9, 2026

  Based on record review and interviews it was determined the facility failed to follow physician's orders for 3 of 5 (#s 1, 3, and 5) sampled residents reviewed for critical lab values and medication errors. The facility failed to follow physician's orders on [DATE] to send Resident 1 to the Emergency Department after a critical lab value was received. The resident died on [DATE]. This put residents at risk for medication errors and death. Findings include: 1. Resident 1 admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine and kidney disease. A [DATE] admission MDS indicated Resident 1 was cognitively intact. […]

• Actual harm, isolatedF689Mar 28, 2023

  Based on interview and record review it was determined the facility failed to assess, monitor and provide treatment timely after spilling hot coffee for 1 of 5 sampled residents (#1) reviewed for accidents. Resident 1 required hospitalization and was diagnosed with 2nd degree burns of the left thigh and back. Findings include: Resident 1 was admitted to the facility in 7/2022 with diagnoses including quadriplegia. Review of a Care Plan dated 12/29/22 revealed the resident required assistance with set up for meals but was otherwise independent with eating and drinking. […]

• Actual harm, isolatedF600Jan 11, 2022

  Based on interview and record review it was determined the facility failed to ensure residents were free from neglect related to a failure to provide proper and necessary care, goods, and services for 2 of 6 residents (#s 10 and 12) reviewed for incontinence and resident rights. Resident 10 developed multiple wounds to the buttocks. Findings include: 1. Resident 10 was admitted to the facility in 8/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/30/20 and 12/1/20 care plans indicated Resident 10 had actual skin impairment with interventions including use a draw sheet or lifting device to move, and boost Resident 10 up in bed and use caution during transfers. […]