Pittsburgh, PA

Spring Hill Rehabilitation And Nursing Center

2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $19,366 in total fines with 71 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

2170 Rhine Street, Pittsburgh, PA

(412) 323-0420

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pollak Holdings

Operator or chain grouping

Approved since

1984-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 2 overall / 1 health / 2 staffing / 4 quality stars

Changed ownership

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

0.92

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.57

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.76

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.26

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

2.99

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.66

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.13

CMS adjusted RN staffing hours

Adjusted total hours

3.99

CMS adjusted total nurse staffing hours

Case-mix index

1.12

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

61%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,645

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.29

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 64.06% · Performance 65.22% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.26

Baseline 4.53 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	68.2%	86.9% 18.7 pts worse	93.4% 25.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 71.8% · Q2 64.7% · Q3 70.6% · Q4 65.7% · 4Q avg 68.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	78.5%	93.5% 15 pts worse	95.5% 17 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 78.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.2%	3.2% 1 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.5% · Q4 4.5% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.5%	6.5% 2 pts better	11.4% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 0.0% · Q3 3.5% · Q4 5.2% · 4Q avg 4.5%
Percentage of long-stay residents who lose too much weight	13.9%	6.5% 7.4 pts worse	5.4% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 16.4% · Q3 9.0% · Q4 7.7% · 4Q avg 13.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.6%	19.9% 0.3 pts better	19.6% About the same	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 22.4% · Q3 20.6% · Q4 21.9% · 4Q avg 19.6%
Percentage of long-stay residents who received an antipsychotic medication	14.8%	18.7% 3.9 pts better	16.7% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 14.9% · Q3 12.5% · Q4 18.5% · 4Q avg 14.8% · 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	23.7%	19.6% 4.1 pts worse	16.3% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 14.8% · Q3 27.1% · Q4 28.8% · 4Q avg 23.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.5%	18.3% 1.2 pts worse	14.9% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 14.5% · Q3 23.8% · Q4 21.1% · 4Q avg 19.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.2%	26.4% 8.2 pts better	19.8% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 19.0% · Q3 8.3% · Q4 17.1% · 4Q avg 18.2%
Percentage of long-stay residents with pressure ulcers	7.3%	5.3% 2 pts worse	5.1% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 5.6% · Q3 4.4% · Q4 4.1% · 4Q avg 7.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	34.6%	68.9% 34.3 pts worse	81.7% 47.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 32.1% · Q3 42.9% · Q4 38.1% · 4Q avg 34.6%
Percentage of short-stay residents who newly received an antipsychotic medication	6.0%	1.5% 4.5 pts worse	1.6% 4.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 13.6% · Q4 5.0% · 4Q avg 6.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	25.4%	68.7% 43.3 pts worse	79.7% 54.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 25.4%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-18 · Fire 2025-04-18

71 health deficiencies

Top issue: Quality of Life and Care (18 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-04-25 · Fire 2024-04-25

23 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-07-14 · Fire 2023-07-14

10 health deficiencies

Top issue: Administration (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-18

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-19

E · Potential for more than minimal harm 2025-04-18

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-05-19

E · Potential for more than minimal harm 2025-04-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-19

E · Potential for more than minimal harm 2025-04-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-05-19

E · Potential for more than minimal harm 2025-04-18

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-05-19

E · Potential for more than minimal harm 2025-04-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-19

C · Minimal harm 2025-04-18

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-05-19

C · Minimal harm 2025-04-18

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-05-19

F · Potential for more than minimal harm 2024-04-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-16

F · Potential for more than minimal harm 2024-04-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-04-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-06

E · Potential for more than minimal harm 2024-04-25

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-06

C · Minimal harm 2024-04-25

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-06-24

C · Minimal harm 2024-04-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-06-24

C · Minimal harm 2024-04-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-06

E · Potential for more than minimal harm 2023-07-14

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-09-08

E · Potential for more than minimal harm 2023-07-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-08

C · Minimal harm 2023-07-14

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-09-08

C · Minimal harm 2023-07-14

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-09-08

C · Minimal harm 2023-07-14

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-09-08

C · Minimal harm 2023-07-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-09-08

C · Minimal harm 2023-07-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-08

Inspection history

Recent health citations

L · Immediate jeopardy 2026-01-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Not marked corrected

J · Immediate jeopardy 2026-01-22

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.

Not marked corrected

J · Immediate jeopardy 2026-01-22

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.

Not marked corrected

F · Potential for more than minimal harm 2026-01-22

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F942 · Resident Rights Deficiencies

Health

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F945 · Infection Control Deficiencies

Health

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F946 · Administration Deficiencies

Health

Provide training in compliance and ethics.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Not marked corrected

E · Potential for more than minimal harm 2026-01-22

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Not marked corrected

D · Potential for more than minimal harm 2026-01-22

F729 · Nursing and Physician Services Deficiencies

Health

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Not marked corrected

D · Potential for more than minimal harm 2026-01-22

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Not marked corrected

D · Potential for more than minimal harm 2026-01-22

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Not marked corrected

D · Potential for more than minimal harm 2026-01-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Not marked corrected

F · Potential for more than minimal harm 2025-12-23

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2026-02-12

E · Potential for more than minimal harm 2025-12-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-02-12

D · Potential for more than minimal harm 2025-12-23

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 2026-02-12

E · Potential for more than minimal harm 2025-12-04

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2026-01-16

E · Potential for more than minimal harm 2025-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-04

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 2026-01-16

D · Potential for more than minimal harm 2025-12-04

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 2026-01-16

D · Potential for more than minimal harm 2025-12-04

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-04

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 2026-01-16

E · Potential for more than minimal harm 2025-07-01

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-08-04

E · Potential for more than minimal harm 2025-07-01

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-08-04

D · Potential for more than minimal harm 2025-07-01

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 2025-08-04

D · Potential for more than minimal harm 2025-07-01

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 2025-08-04

D · Potential for more than minimal harm 2025-07-01

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-04

D · Potential for more than minimal harm 2025-07-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-08-04

D · Potential for more than minimal harm 2025-07-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-04

E · Potential for more than minimal harm 2025-04-18

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 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F850 · Administration Deficiencies

Health

Hire a qualified full-time social worker in a facility with more than 120 beds.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-09

E · Potential for more than minimal harm 2025-04-18

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-06-09