Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Friendship Village Of South Hi during CMS and state inspections, most recent first.
A resident with a traumatic brain injury, subdural hematoma, and cervical fracture reported to an RN that during care he was boosted in bed, his head struck the headboard, and he experienced increased numbness and tingling in his left forearm and fingers, with pins and needles in his upper extremities and feet. The RN documented the complaint and noted no obvious head injury, no increased pain, and an intact CTO brace with a missing foam piece, and the resident’s care plan called for caution during transfers and bed mobility. However, nursing staff did not enter an incident report or initiate an investigation of this allegation of potential rough handling/abuse as required by facility policy and state law, and the event was not reported to administration until the family later raised concerns, at which point leadership confirmed the failure to immediately report and investigate.
Grievance boxes on three nursing units were mounted at heights between 55 and 61 inches, making them inaccessible to residents in wheelchairs. On one unit, an armchair further blocked access to the box. The Nursing Home Administrator confirmed the lack of accessibility, which did not comply with facility policy or federal accessibility requirements.
Thirteen residents with significant medical needs did not receive timely assistance with ADLs, as evidenced by prolonged call light response times ranging from 20 minutes to over an hour. Multiple residents and families reported repeated delays, and facility records confirmed these extended wait times, despite residents' dependence on staff for essential care.
Surveyors found that two medication rooms contained multiple expired medical supplies and medications, including dressings, ointments, and syringes, as well as personal belongings of former residents. The DON confirmed that the facility failed to ensure proper storage and disposal of these items, contrary to facility policy.
A resident who required a two-person assist for transfers was moved by a single CNA, resulting in a deep skin tear on the right shin that required 17 sutures. The resident, with multiple medical conditions and non-weight bearing status, was injured when their leg struck the wheelchair leg rest holder during the transfer. The CNA did not check the resident's transfer status as documented in the Kardex, leading to neglect and actual harm.
A resident with severe cognitive impairment and multiple diagnoses was found to have their bed placed against the wall without a physician's order or documented medical reason. Facility policy and state regulations require written authorization for physical restraints, but no such documentation was present in the clinical record or care plan, and staff confirmed the lack of compliance.
A resident with Alzheimer's and other medical conditions was administered Seroquel, a psychotropic medication, both as a scheduled and PRN order for agitation and depression. The PRN order exceeded the facility's 14-day policy limit, and there was no documented clinical rationale or evidence of behaviors to justify continued use. Staff confirmed the failure to ensure the medication regimen was free from unnecessary psychotropic medication.
A resident who required a two-person assist for transfers due to multiple medical conditions was transferred by a single CNA, contrary to the care plan and Kardex instructions. During the transfer, the resident's leg struck the wheelchair leg rest holder, causing a deep skin tear that required 17 sutures. The CNA did not verify the resident's transfer status before performing the transfer alone, resulting in actual harm.
The facility did not post the required contact information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups, making this information inaccessible to residents and their representatives. This was confirmed during observations and an interview with the NHA.
The facility did not display required written information about how to apply for and use Medicare and Medicaid benefits, or how to receive refunds for previous payments covered by these benefits. This was confirmed during observations and an interview with the NHA.
The facility did not revise or update care plans for two residents to reflect their current care needs. One resident's care plan lacked interventions for a bed placed against the wall, which acted as a physical restraint, while another resident's care plan did not accurately reflect their level of independence with oral care and lacked documentation of personal hygiene services. Facility leadership confirmed these deficiencies.
The facility did not provide or document required training on the Quality Assurance and Performance Improvement (QAPI) Program for staff. Review of records and staff interviews confirmed the absence of QAPI-related education, and the administrator acknowledged the deficiency.
The facility failed to provide four residents the opportunity to formulate an advance directive, as required by policy. Despite being admitted with various health conditions, their clinical records lacked documentation of being offered this right. The DON and NHA confirmed this deficiency during an interview.
The facility did not notify the State Ombudsman Office of resident transfers and discharges for over four years, from 2019 to 2024. This was confirmed through document reviews and interviews, with the Nursing Home Administrator acknowledging the lapse. The State Ombudsman Office had not received notifications since 2019, violating resident rights as per PA Code: 201.29(f)(g).
Failure to Immediately Report and Investigate Resident Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate a resident’s allegation of potential abuse/neglect as required by policy and state law. Facility policy (RISKWATCH Incident/Accident Occurrence Reporting System) required that incidents such as alleged abuse, rough handling, equipment-related incidents involving a resident, and injuries of unknown origin be entered completely and accurately by the licensed nurse or first responder prior to the end of the shift and as close to the time of the incident as possible, with documentation on the 24-hour report and alert monitoring per change of condition standards. A resident with diagnoses including traumatic subdural hematoma, displaced fracture of the seventh cervical vertebra, and traumatic brain injury reported to an RN that during care the previous night, when he was being boosted in bed, his head hit the headboard and he was experiencing increased numbness and tingling in his left forearm and first and second fingers, with pins and needles in the left upper extremity, right hand, and both feet. The RN documented that there was no obvious head injury or increased pain and that the cervical-thoracic orthosis brace was intact, though missing a foam piece underneath the bottom portion. Despite this report from the resident, and the resident’s plan of care indicating he had potential/actual impairment related to a cervical collar and impaired mobility requiring use of caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces, the nursing staff did not make an incident report or initiate an investigation at that time. The Nursing Home Administrator confirmed that the resident and family reported the event to nursing staff on the date of the RN’s note without staff making a report in accordance with facility policy and state requirements. An investigation was not initiated until later, after the family emailed facility administration with concerns related to the event. The Nursing Home Administrator and Director of Nursing acknowledged that the facility failed to immediately report and investigate the resident’s allegation in response to allegations of abuse, neglect, exploitation, or mistreatment.
Grievance Boxes Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents on three nursing units: Dogwood, Pinewood, and Specialty Care. Observations revealed that the grievance boxes were mounted at heights of approximately 55 inches, 61 inches, and 60 inches above the floor, respectively, which placed them out of reach for residents using wheelchairs. Additionally, on the Specialty Care unit, an armchair was found blocking access to the grievance box, further limiting accessibility. Interviews with the Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents in these locations. The facility's policy supports residents' and family members' rights to voice grievances without discrimination or reprisal, and federal regulations require that grievance procedures be accessible to all residents, including those with disabilities. However, the facility did not comply with these requirements, as evidenced by the placement and obstruction of the grievance boxes.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary care and services to thirteen out of twenty-four residents who required assistance with activities of daily living (ADLs). Facility policy states that residents unable to perform ADLs independently must receive appropriate care to maintain nutrition, grooming, and hygiene. However, multiple residents and their families reported excessive wait times for staff assistance after activating call lights, with documented delays ranging from 20 minutes to over an hour. These concerns were corroborated by group interviews, resident council minutes, and grievance records, all indicating ongoing dissatisfaction with response times. Clinical record reviews revealed that affected residents had significant medical conditions such as malignant neoplasm of the colon, diabetes mellitus, dementia, hip fractures, Parkinson's disease, and other chronic illnesses. Many required substantial or maximal assistance with personal hygiene, mobility, and toileting, as indicated by their Minimum Data Set (MDS) assessments. Despite these needs, call light audits consistently showed prolonged response times, with several instances exceeding 30 minutes and some over an hour, directly impacting residents who were dependent on staff for essential care. Interviews with residents, family members, and facility leadership confirmed the pattern of delayed responses. Residents expressed frustration and described frequent experiences of waiting extended periods for help, particularly with ADLs. The facility's own documentation, including call light logs and grievance records, substantiated these reports. The deficiency was acknowledged by both the Nursing Home Administrator and the Director of Nursing, who confirmed that necessary care and services were not consistently provided to the identified residents.
Improper Storage and Disposal of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and disposed of in two out of three medication rooms, as required by facility policy and regulatory standards. During observations, multiple expired medical supplies and medications were found in both the Secure Care Unit and Dogwood Unit medication rooms. Items identified included expired calcium alginate dressings, gelling fiber dressings, a latex Foley catheter, Bacitracin zinc ointment, and various other medical supplies and medications with expiration dates ranging from 2021 to 2025. Additionally, the facility policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications or biologicals, but this was not followed as evidenced by the presence of these expired items. Further, in the Dogwood medication room, personal belongings of former residents, such as hearing aids, eyeglasses, a cell phone, and other miscellaneous articles, were found stored under the sink. These items belonged to residents who had been discharged from the facility as far back as 2020. The Director of Nursing confirmed during an interview that the facility did not ensure proper storage or disposal of medical supplies, medications, and personal items in the medication rooms.
Failure to Follow Transfer Protocols Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, and diabetes, and was non-weight bearing on the left lower extremity. The resident's care plan and Kardex clearly indicated the need for a two-person assist for all transfers, and the facility's policies required staff to follow these directives to prevent harm. During the transfer from wheelchair to bed, the CNA performed the transfer alone, contrary to the resident's documented needs. As a result, the resident sustained a deep skin tear on the right shin, which was discovered after the transfer when the resident's pants were removed. The wound was significant, measuring 4.5 cm by 5 cm by 1 cm, with exposure of adipose tissue, and required 17 sutures at the hospital. The incident was attributed to the resident's leg striking the wheelchair leg rest holder during the improper transfer. Staff interviews confirmed that other nurse aides were able to describe how to access and follow a resident's required transfer status. The Nursing Home Administrator acknowledged that the facility failed to protect the resident from neglect, as the CNA did not check the transfer status on the Kardex and did not provide the required level of assistance, resulting in actual harm to the resident.
Failure to Ensure Resident Free from Physical Restraint Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, high blood pressure, and lumbar radiculopathy was found to have their bed placed against the wall without a physician's order or documented medical justification. The facility's policy requires that residents be free from physical restraints unless authorized in writing by a physician for a specific and limited period or in emergencies. In this case, there was no documentation in the resident's clinical record, plan of care, or progress notes to support the use of the bed against the wall as a restraint or to indicate a medical reason for this intervention. The resident in question had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, there was no evidence of a physician's order or care plan goal related to the bed placement. During staff interviews, it was confirmed that the facility failed to ensure the resident was free from the use of a physical restraint without proper authorization, as required by both facility policy and state regulations.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to the facility's policy, psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and must be supported by documented clinical rationale. For one resident with diagnoses including Alzheimer's disease, high blood pressure, and lumbar radiculopathy, the clinical record showed ongoing orders for Seroquel (Quetiapine) both as a scheduled and PRN medication for agitation and depression. The PRN order for Seroquel exceeded the 14-day limit set by policy, and there was no documentation of behaviors or clinical justification for continued use during the specified period. Additionally, a new PRN order for Seroquel was written at the request of the resident's family, again without documented evidence of behaviors or clinical rationale in the progress notes. Staff interviews confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by both facility policy and regulatory standards.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required a two-person assist as documented in the care plan and Kardex, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, diabetes, and was non-weight bearing on the left lower extremity. The care plan specifically indicated the need for caution during transfers to prevent skin injuries, and the Kardex clearly stated the requirement for a two-person assist for transfers. During the transfer from wheelchair to bed, the CNA performed the task alone, contrary to the documented requirements. The resident's right shin struck the wheelchair leg rest holder during the transfer, resulting in a deep skin tear. The injury was discovered after the transfer when the resident's pants were removed, revealing a large, deep skin tear with exposure of adipose tissue. The wound measured 4.5 cm by 5 cm, was 1 cm wide and deep, and required immediate medical attention. The incident was reported by the CNA and assessed by nursing staff, who confirmed the extent of the injury. The resident was sent to the hospital, where the wound required 17 sutures. Documentation and staff interviews confirmed that the CNA did not check the resident's transfer status prior to the transfer and did not follow the required two-person assist protocol, directly leading to the resident's injury.
Failure to Post Required State Agency and APS Contact Information
Penalty
Summary
The facility failed to post required information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups in a manner accessible and understandable to residents and their representatives. During observations conducted in the building, it was found that there was no posted list containing the names, addresses (mailing and email), and telephone numbers of State agencies such as the State Survey Agency, State licensure office, APS, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the required postings.
Failure to Display Medicare and Medicaid Benefit Information
Penalty
Summary
The facility failed to display written information for residents and their responsible persons regarding how to apply for and use Medicare and Medicaid benefits, as well as how to receive refunds for previous payments covered by these benefits. During observations conducted in the building, it was noted that this required information was not posted. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not have the necessary written information displayed as required by regulations. No information was provided to residents or applicants for admission about these benefits or the refund process.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update care plans for two of eighteen residents to accurately reflect their current status, as required by facility policy and state regulations. For one resident with Alzheimer's, high blood pressure, and lumbar radiculopathy, the care plan did not include goals or interventions related to the resident's bed being placed against the wall, which created a physical restraint on one side. There was also no physician order for this intervention, and the care plan did not address this aspect of the resident's care. For another resident with non-Alzheimer's dementia, high blood pressure, and depression, the care plan indicated total dependence on staff for oral care. However, nursing progress notes documented that the resident was independent in oral care, and there was a lack of documentation regarding the provision and assistance level of personal hygiene services on multiple dates. Interviews with the resident and family confirmed that oral care was not provided daily or routinely. The DON and Nursing Home Administrator acknowledged the failure to update care plans for these residents.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to provide documented training on its Quality Assurance and Performance Improvement (QAPI) Program for staff, as required by its own Facility Assessment and state regulations. Review of facility documents and education records did not show evidence of QAPI-related training for staff. During interviews, the Nursing Home Administrator was unable to provide documentation or confirm that any staff education included QAPI content, and ultimately acknowledged that the required training had not been conducted or documented. This deficiency was identified through review of records and staff interviews, with no additional information or documentation available to demonstrate compliance.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 10/1/24 and 1/4/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of four residents, who were admitted with various diagnoses including diabetes, anxiety, high blood pressure, dementia, muscle weakness, and a history of falls, did not contain an advance directive or documentation that they were given the opportunity to formulate one. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the absence of such documentation in the clinical records of these residents, indicating a failure to uphold the residents' rights as per 28 Pa. Code: 201.29(b)(d)(j) regarding resident rights.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period exceeding four years, from September 2019 through September 2024. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. The State Ombudsman Office confirmed that they had not received the required notifications since August 2019. The Nursing Home Administrator acknowledged the failure to report these transfers and discharges as required by the Pennsylvania Code: 201.29(f)(g) concerning resident rights.
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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 Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgeville Rehabilitation & Care Center | 1.7 mi | ★★★★★ | 21 | 2 |
| Mcmurray Hills Rehabilitation And Healthcare Cente | 3.1 mi | ★★★★★ | 3 | 0 |
| Peters Township Post Acute | 3.1 mi | ★★★★★ | 11 | 0 |
| Meadowcrest Rehabilitation & Healthcare Center | 3.9 mi | ★★★★★ | 28 | 1 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 4 mi | ★★★★★ | 21 | 0 |
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