Spring Hill Rehabilitation And Nursing Center
SPRING HILL REHABILITATION AND NURSING CENTER in PITTSBURGH, PA — inspection on February 26, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Resident Rights policy dated 9/22/25, indicated the facility will inform the resident of his or her resident rights during the stay in the facility.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.
Review of Resident R1's admission record indicated she was admitted to the facility on [DATE].
Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.
Review of Resident R1's physician orders dated 9/29/25, indicated low air loss mattress to bed.
Check placement and functioning every shift.
During an interview on 2/25/26, at 1:50 p.m.
Resident R1 stated, On Sunday (2/22/26), the motor for the foot part of my bed broke. I haven't been able to put my legs up or down while I'm in bed.
During an observation on 2/25/26, at 1:55 p.m. when Resident R1 used the bed control to move the leg area of the bed up and down, the bed made a loud noise, and the bottom of the bed did not move up or down.
During an interview on 2/25/26, at 2:07 p.m.
Maintenance Director Employee E3 stated his department was notified that Resident R1's bed was broken and needed a new motor to control the lower portion of his bed. I took the specs off the bed to put an order in to purchase a new motor. I don't know if it's been ordered and confirmed that Resident R1's bed was not in working order.
During an interview on 2/25/26, at 3:15 p.m.
Director of Nursing confirmed that the facility failed to maintain resident rights in having a bed in working condition for one of two residents (Resident R1). 28 Pa.
Code 211.10(a)(c)(d) Resident care policies. 28 Pa.
Code 211.12(d)(1)(2)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
During an interview on 2/27/26, at 9:15 a.m. RN
the book and I was doing the meds.
During the initial count everything was correct and then she went
the controlled substance record.
For example, Resident R3's narcotic count went from 38, to 35, and then ended with 32.
Another one , Resident R5's, said he was given Oxycodone all throughout the night but it was reported to me that he slept all night. I don't believe he got any medication.
Another resident, Resident R4's, Oxycodone started at 12 and ended with nine.
The initial narcotic counts matched but the narcotic sheets were not signed out correctly.
During an interview on 2/26/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents are free from misappropriation of property for five of seven residents (Resident R1, R2, R3, R4, and R5). 28 Pa.
Code: 211.12 (d)(1)(5) Nursing services. 28 Pa.
Code: 201.29(a) Resident rights.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
Review of facility policy Licensed Nurse Credentialing and License Verification reviewed 9/22/25, indicated all licensed nurses will have their credentials and license verified upon employment.
During an interview on 2/25/26, at 3:16 p.m.
Director of Nursing confirmed that Registered Nurse (RN) Employee E1 was an agency nurse who worked in the facility 2/21/26 through 2/22/26.
During a review of RN Employee E1 personnel folder on 2/26/26, at 10:15 a.m. included a license verification that was conducted on 2/24/26, three days after working in the facility.
During an interview on 2/26/26, at 2:40 p.m. the Human Resources Employee E2 confirmed that the facility failed to have documented evidence of license verification prior to first working shift for RN Employee E1. 28 Pa.
Code 201.14(a) Responsibility of licensee. 28 Pa.
Code 201.18(b)(1) Management. 28 Pa.
Code 201.19 (3)(7) Personnel policies and procedures.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
During an interview on 2/27/26, at
to 7:00 p.m.
They put me on the same cart. I didn't notice any discrepancies initially because when we counted, she had the book and I was doing the meds.
During the initial count everything was correct and then she went to count with someone else.
Later in the day, I started to see discrepancies in the documentation on the controlled substance record.
For example, Resident R3's narcotic count went from 38, to 35, and then ended with 32.
Another one, Resident R5's, said he was given Oxycodone all throughout the night but it was reported to me that he slept all night. I don't believe he got any medication.
Another resident, Resident R4's, Oxycodone started at 12 and ended with nine.
The initial narcotic counts matched but the narcotic sheets were not signed out correctly.
During an interview on 2/26/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to report allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5). 28 Pa.
Code: 201.14(a) Responsibility of licensee. 28 Pa.
Code: 211.10(d) Resident care policies. 28 Pa.
Code: 201.18 (b) (1) (e) (1) Management. 28 Pa.
Code: 211.12 (d) (1) (2) (5) Nursing services.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
During the initial count everything was correct and then she went to count with someone else.
Later in the day, I started to see discrepancies in the documentation on the controlled substance record.
For example, Resident R3's narcotic count went from 38, to 35, and then ended with 32.
Another one , Resident R5's, said he was given Oxycodone all throughout the night but it was reported to me that he slept all night. I don't believe he got any medication.
Another resident, Resident R4's, Oxycodone started at 12 and ended with nine.
The initial narcotic counts matched but the narcotic sheets were not signed out correctly.
During an interview on 2/26/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct a thorough investigation of allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5). 28 Pa.
Code: 201.14(a) Responsibility of licensee. 28 Pa.
Code: 201.18 (b)(1) Management. 28 Pa.
Code: 211.10 (c)(d) Resident Care policies. 28 Pa.
Code: 211.12 (d)(1)(2)(3)(5) Nursing services.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
Review of Resident R1's admission record indicated she was admitted to the facility on [DATE].
Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.
Review of Resident R1's care plan dated 7/17/25, revealed the resident was care planned for chronic pain.
Interventions included to administer medication per physician orders.
Review of Resident R1's physician order dated 12/23/25, indicated to administer Oxycodone (a pain medication) 5 milligrams, one tablet by mouth, every eight hours as needed.
During an interview on 2/25/26, at 11:45 a.m.
Resident R1 reported that he requested an Oxycodone for breakthrough pain and did not receive his Oxycodone Sunday, Monday, and Tuesday this week according to the physician order and stated, I was in a lot more pain than normal. It affected some activities that I do. I didn't do my laundry, I didn't sleep well. I didn't stay out of bed as long as I usually do. I was pretty miserable.
During a review of Resident R1's clinical record on 2/25/26, revealed that the Medication Administration Record (MAR) was blank, which indicated that resident did not receive Oxycodone as needed.
During a review of Resident R1's chart on 2/25/26, at 2:30 p.m. failed to contain the controlled substance record to review documentation of Oxycodone.
During an interview on 2/25/26, at 2:35 p.m.
Registered Nurse Employee E11 confirmed that the controlled substance record was missing and unable to identify if Resident R1 had Oxycodone given per request.
During an interview on 2/26/26, at 2:55 p.m.
Clinical Consultant Employee E9 reviewed February MAR and confirmed that 2/22/26, 2/23/26, and 2/24/26 were blank, indicating Resident R1 did not receive Oxycodone per request.
During an interview on 2/26/26, at 3:00 p.m.
Clinical Consultant Employee E9 confirmed that the facility failed to provide effective pain management for one of five residents reviewed (Resident R1), which resulted in excessive pain, poor sleeping, and decreased level of functioning of activities of daily living, causing harm to Resident R1. 28 Pa.
Code 211.12(d)(3)(5) Nursing Services.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
Review of Resident R1's admission record indicated she was admitted to the facility on [DATE].
Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.
During an interview on 2/25/26, at 11:45 a.m.
Resident R1 stated that he should be receiving two Singulair (a medication used to treat allergies) 10 mg (milligram) tablets every day and that he has been only receiving one tablet.
During a review of Resident R1's physician orders dated 1/25/26, revealed Singulair 10 mg, give two tablets every day.
During an observation of Resident R1's medication on 2/26/26, at 11:20 a.m. with Clinical Consultant Employee E9 revealed that pharmacy is sending Singulair 10 mg, quantity one to be administered.
During a phone interview on 2/26/26, at 11:41 a.m.
Pharmacist Employee E10 confirmed that Resident R1 has been receiving Singulair 10 mg, one tablet and that the pharmacy cycle order is incorrect and stated that he will get it fixed.
During an interview on 2/26/26, at 3:00 p.m.
Clinical Consultant Employee E9 confirmed that the facility failed to ensure that the pharmacy provided medications timely for one of two residents reviewed (Resident R1). 28 Pa.
Code211.12(d)(1)(3)(5) Nursing services.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
Based on findings identified, the facility failed to timely and effectively manage five of five allegations of misappropriation of resident belongings that included narcotic diversion.
The DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.
During an interview on 2/25/26, at 3:15 p.m. the DON stated he had the investigation of the incident upstairs in his office and would provide state agency (SA) with a copy.
During an interview on 2/25/26, at 4:45 p.m. the DON confirmed that he failed to have an investigation for the misappropriation of resident belongings that included narcotic diversion for five of five residents.
When SA asked the DON, Do you have an investigation concerning the narcotic diversion? the DON replied No.
During an interview on 2/26/26, at 3.00 p.m. the NHA confirmed that the DON failed to timely and effectively manage five allegations of resident misappropriation of belongings which included narcotic diversion for five of five residents (Resident R1, R2, R3, R4, and R5). 28 Pa.
Code 201.14(a) Responsibility of licensee. 28 Pa.
Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services.
395666 02/26/2026
Spring Hill Rehabilitation and Nursing Center 2170 Rhine Street Pittsburgh, PA 15212
Based on a review of facility documents and interviews with staff it was determined that the facility
process.
Findings include: During a complaint survey on 2/25/26, at 9:00 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that the state agency (SA) team will be investigating five complaints.
During an interview on 2/25/26, at 2:30 p.m. the SA was made aware that a nurse over the weekend was taking narcotics and that the police were notified.
During an interview on 2/25/26, at 3:15 p.m. the Director of Nursing confirmed that a nurse had taken narcotics and that the police were notified on 2/22/26.
The SA asked the DON for the facility's complete investigation for the incident to review.
The DON stated, The investigation is in my office, I can go get it for you.
The SA requested a copy of the full investigation at this time.
During an interview on 2/25/26, at 3:55 p.m. the Interim Assistant Director of Nursing was made aware that SA was waiting for the DON's complete investigation of incident.
During an interview on 2/25/26, at 4:11 p.m. the Nursing Home Administrator (NHA) was made aware that SA was waiting for the DON's complete investigation of incident.
During an interview on 2/25/26, at 4:45 p.m. the DON confirmed that he failed to have an investigation for the misappropriation of resident belongings that included narcotic diversion for five of five residents.
When SA asked the DON, Do you have an investigation concerning the narcotic diversion? the DON replied No.
The SA asked, When you said your investigation was in your office and you would make a copy for review, you didn't have an investigation? the DON replied No.
During an interview on 2/25/26, at 4:50 p.m. the NHA and DON confirmed that the facility did not have an investigation for five of five resident misappropriations of resident property that included narcotic diversion and were made aware that the extended amount of time waiting for the facilities investigation that did not exist was a delay in survey.
The SA returned to facility on 2/26/26, at 8:30 a.m. to continue investigating the misappropriation of resident property. 28 Pa.Code 201.14(a) Responsibility for licensee. 28 Pa.Code 201.18(d)(e)(1) Management.