Cycle 1
Health 2025-12-02 · Fire 2024-10-04
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pittsburgh, PA
Friendship Village Of South Hi
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1290 Boyce Road, Pittsburgh, PA
(724) 941-3100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
89
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
1985-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,392
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.51
Baseline 20.92% · Performance 20.73% · Measure score 1.51 · Achievement 1.51 · Improvement 0
Healthcare-associated infections
3.88
Baseline 6.93% · Performance 6.68% · Measure score 3.88 · Achievement 3.88 · Improvement 0.83
Total nurse turnover
4.58
Baseline 63.27% · Performance 44.94% · Measure score 4.58 · Achievement 4.58 · Improvement 4.27
Adjusted total nurse staffing
3.25
Baseline 4.02 hours · Performance 4 hours · Measure score 3.25 · Achievement 3.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 10.49% · Lower 95% interval 8.02% |
| Discharge to community | 53.59% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 51.63% · Lower 95% interval 46.41% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.9% |
95.27%
1.6 pts better
|
Numerator 125 · Denominator 129 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 129 |
| Discharge self-care score | 42.39% |
53.69%
11.3 pts worse
|
Numerator 39 · Denominator 92 |
| Discharge mobility score | 44.57% |
50.94%
6.4 pts worse
|
Numerator 41 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 5 · Denominator 129 · Adjusted rate 4.25% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 5.26% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 0.85% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 117 |
| Staff flu vaccination coverage | 96.77% |
42%
54.8 pts better
|
Numerator 120 · Denominator 124 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 40 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 82 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 48.53% |
25.2%
23.3 pts better
|
Numerator 33 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
86.9%
0.5 pts better
|
93.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 86.5% · Q3 84.0% · Q4 91.5% · 4Q avg 87.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
93.5%
2.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
6.5%
2.3 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.0% · Q3 4.2% · Q4 4.8% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.5%
0.9 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.3% · Q3 10.3% · Q4 0.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
19.9%
1.6 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 29.3% · Q3 22.5% · Q4 18.4% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
18.7%
11.4 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.7% · Q3 5.9% · Q4 9.7% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.8% |
19.6%
1.2 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 32.7% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
18.3%
0.7 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 38.5% · Q3 8.3% · Q4 9.1% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
26.4%
0.1 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 26.4% · Q3 28.2% · Q4 34.6% · 4Q avg 26.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.3%
About the same
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.4% · Q3 7.8% · Q4 1.6% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.6% |
68.9%
5.3 pts worse
|
81.7%
18.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.5% · Q2 58.9% · Q3 62.0% · Q4 58.7% · 4Q avg 63.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
9.8%
3.5 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 11.5% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.0% |
68.7%
1.7 pts worse
|
79.7%
12.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
23.1%
1.6 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 21.8% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-04 · Fire 2023-10-12
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-10-12 · Fire 2022-12-01
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-10-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-10-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-23
C · Minimal harm
2024-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-23
E · Potential for more than minimal harm
2023-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-10-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-29
C · Minimal harm
2023-10-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-29
C · Minimal harm
2023-10-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-29
E · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-02
C · Minimal harm
2022-12-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-02
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-12-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-12-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-12-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-12-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-12-02
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-12-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-04
C · Minimal harm
2025-12-02
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-12-04
C · Minimal harm
2025-12-02
F579 · Resident Rights Deficiencies
Health
Provide information about how to apply for and use Medicare and Medicaid benefits.
Corrected 2025-12-04
C · Minimal harm
2025-12-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-04
C · Minimal harm
2025-12-02
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-12-04
D · Potential for more than minimal harm
2024-10-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-06
C · Minimal harm
2024-10-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-06
E · Potential for more than minimal harm
2023-10-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-10-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-29
Penalties and ownership
What sits behind the stars
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Lifespace, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Blackford, Gary
Corporate Director · Individual
Darkey-Hrinya, Joyce
Corporate Director · Individual
Dutra, Ana
Corporate Director · Individual
Fields, Venita
Corporate Director · Individual
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Officer · Individual
Jensen, Claus
Corporate Director · Individual
Kresse, Nikki
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Mcdonough, Amy
Corporate Director · Individual
Pope, Erin
Corporate Officer · Individual
Salamino, Jenifer
Corporate Director · Individual
Sokeye, Jonathan
Corporate Director · Individual
Spangler, Patrick
Corporate Director · Individual
Stover, Dina
W-2 Managing Employee · Individual
Stretch, Clyde
Corporate Director · Individual
Williams, David
Corporate Director · Individual
Yanofsky, Neal
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bridgeville Rehabilitation & Care Center
Bridgeville, PA
1-star overall rating with 1-star inspections with abuse icon flag with $273,222 in total fines with 27 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
McMurray Hills Rehabilitation and Healthcare Cente
Mcmurray, PA
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Peters Township Post Acute
Mcmurray, PA
3-star overall rating with 3-star inspections with $8,190 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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