Spring Hill Rehab: ADL Care Failures for Dying Resident - PA
The man, identified in inspection records only as Resident R5, was admitted to Spring Hill Rehabilitation and Nursing Center on Rhine Street after a hospice referral determined he needed more care than could be provided at home. His diagnosis was liver cell carcinoma.
What inspectors found when they reviewed his clinical record was a gap. The last documented care during the overnight shift on November 20, 2025 was noted at some point during the 11 p.m. to 7 a.m. window. The next entry was a physician note timestamped 1:23 p.m. the following afternoon. In between, nothing. No record of a bath. No record of help eating. No documentation that anyone had assisted him with the basic tasks that a man in his condition could not perform on his own.
He was later sent to the hospital after sustaining a fall.
The inspection, conducted December 23, 2025, was a complaint survey. Inspectors reviewed the records of five residents total. R5 was the only one where this kind of gap was found.
At noon that day, inspectors sat down with the Director of Nursing and the Nursing Home Administrator. Both confirmed they could not locate documentation showing R5 had received activities of daily living care during his stay. Five minutes later, at 12:05 p.m., they were told directly: the facility had failed to provide ADL care to this resident.
Neither official disputed it.
Spring Hill's own written policy, dated September 22, 2025, states that care and services will be provided for bathing, dressing, grooming and oral care, toileting, transfer and ambulation, and eating, including meals and snacks. The policy existed. The documentation did not.
The violation was cited under F0677, which covers the obligation to provide care and assistance with daily living activities for residents who cannot perform them independently. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
That classification reflects the regulatory framework's language, not necessarily what it meant for R5. He was a hospice patient. He had been referred to the facility precisely because his needs exceeded what could be managed at home. The activities of daily living that went undocumented — bathing, eating — are not optional comforts for someone in that condition. They are the baseline.
Whether R5 received that care and it simply wasn't recorded, or whether the care itself was never provided, is something the inspection report cannot answer. The Director of Nursing and the Administrator said they couldn't find the records. That is what the record shows.
He fell. He was sent to the hospital. What happened after that is not in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Hill Rehabilitation and Nursing Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
SPRING HILL REHABILITATION AND NURSING CENTER in PITTSBURGH, PA was cited for violations during a health inspection on December 23, 2025.
His diagnosis was liver cell carcinoma.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.