Cycle 1
Health 2025-05-23 · Fire 2025-05-23
10 health deficiencies
Top issue: Resident Rights (6 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Bethel Park, PA
South Hills Post Acute
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
60 Highland Road, Bethel Park, PA
(412) 831-6050
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1987-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.94
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
49%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,578
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.28
Baseline 21.62% · Performance 21.26% · Measure score 0.28 · Achievement 0 · Improvement 0.28
Healthcare-associated infections
6.79
Baseline 6.36% · Performance 5.80% · Measure score 6.79 · Achievement 6.79 · Improvement 3.56
Total nurse turnover
3.45
Baseline 57.89% · Performance 49.59% · Measure score 3.45 · Achievement 3.45 · Improvement 2.01
Adjusted total nurse staffing
0
Baseline 3.50 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.9% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 232 · Observed rate 13.36% · Lower 95% interval 8.95% |
| Discharge to community | 56.3% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 50% · Lower 95% interval 48.81% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.9% |
95.27%
2.4 pts worse
|
Numerator 144 · Denominator 155 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 155 |
| Discharge self-care score | 43.56% |
53.69%
10.1 pts worse
|
Numerator 44 · Denominator 101 |
| Discharge mobility score | 45.54% |
50.94%
5.4 pts worse
|
Numerator 46 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 5 · Denominator 155 · Adjusted rate 2.9% |
| Healthcare-associated infections requiring hospitalization | 5.8% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 4.58% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 113 |
| Staff flu vaccination coverage | 63.43% |
42%
21.4 pts better
|
Numerator 111 · Denominator 175 |
| Discharge function score | 51.49% |
56.45%
5 pts worse
|
Numerator 52 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 78 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 11.63% |
25.2%
13.6 pts worse
|
Numerator 10 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
93.5%
5.5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.2% · Q3 1.2% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
6.5%
2.9 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 7.4% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.5%
2.9 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 1.4% · Q4 5.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
19.9%
9.3 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.2% · Q3 11.0% · Q4 8.9% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
18.7%
3.7 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 22.2% · Q3 23.0% · Q4 20.6% · 4Q avg 22.4% · 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 | 24.5% |
19.6%
4.9 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 40.6% · Q3 25.3% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.2% |
18.3%
6.9 pts worse
|
14.9%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 37.8% · Q3 8.7% · Q4 22.7% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.9% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.3% · Q3 0.0% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
26.4%
0.7 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 30.2% · Q3 22.8% · Q4 28.1% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.3%
2.4 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.9% · Q3 6.3% · Q4 5.8% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
68.9%
26.8 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 94.6% · Q3 95.5% · Q4 95.5% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
9.8%
1.7 pts worse
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.2% · Q3 2.0% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
68.7%
21.9 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
23.1%
0.7 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 26.2% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-02 · Fire 2023-06-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-23
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-20
C · Minimal harm
2025-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
E · Potential for more than minimal harm
2024-04-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-04-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-10
E · Potential for more than minimal harm
2023-06-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-05
C · Minimal harm
2023-06-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-05
C · Minimal harm
2023-06-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-05
C · Minimal harm
2023-06-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-05-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-05-23
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-05-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-18
C · Minimal harm
2025-05-23
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 2025-06-18
C · Minimal harm
2025-05-23
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-18
C · Minimal harm
2025-05-23
F579 · Resident Rights Deficiencies
Health
Provide information about how to apply for and use Medicare and Medicaid benefits.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-04-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-04-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-24
D · Potential for more than minimal harm
2024-05-15
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 2024-06-14
E · Potential for more than minimal harm
2024-04-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-26
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 2024-05-31
D · Potential for more than minimal harm
2024-03-21
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 2024-04-26
E · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
E · Potential for more than minimal harm
2023-06-02
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 2023-07-05
E · Potential for more than minimal harm
2023-06-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
Ownership
Apt, Frederick
Operational/Managerial Control · Individual
Grimm, Marcie
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
Operational/Managerial Control · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
Operational/Managerial Control · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr
Pittsburgh, PA
2-star overall rating with 1-star inspections with 26 recent health deficiencies
#2
Concordia Of The South Hills
Pittsburgh, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Asbury Health Center
Pittsburgh, PA
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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