Monroeville, PA

Concordia At The Cedars

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

4363 Northern Pike, Monroeville, PA

(412) 373-3900

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

59

Certified beds

Average residents

55

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Concordia Lutheran Ministries

Operator or chain grouping

Approved since

1998-09-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 3 overall / 3 health / 3 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

0.76

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.27

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.04

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.07

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.03

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.64

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.42

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

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.48

CMS adjusted total nurse staffing hours

Case-mix index

1.60

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,790

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

Performance score

47.73

Composite VBP score used to determine payment impact.

Payment multiplier

1.0013

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.16

Baseline 21.62% · Performance 19.50% · Measure score 4.16 · Achievement 4.16 · Improvement 4.11

Healthcare-associated infections

7.46

Baseline 5.58% · Performance 5.61% · Measure score 7.46 · Achievement 7.46 · Improvement 0

Total nurse turnover

5.55

Baseline 33.93% · Performance 40.98% · Measure score 5.55 · Achievement 5.55 · Improvement 0

Adjusted total nurse staffing

1.92

Baseline 3.57 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.88%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 106 · Observed rate 11.32% · Lower 95% interval 7.9%
Discharge to community	60.96%	50.57% 10.4 pts better	No Different than the National Rate · Eligible stays 103 · Observed rate 56.31% · Lower 95% interval 48.14%
Medicare spending per beneficiary	0.83	1.02 0.2 pts better
Drug regimen review with follow-up	97.62%	95.27% 2.4 pts better	Numerator 82 · Denominator 84
Falls with major injury	2.38%	0.77% 1.6 pts worse	Numerator 2 · Denominator 84
Discharge self-care score	72.73%	53.69% 19 pts better	Numerator 48 · Denominator 66
Discharge mobility score	68.18%	50.94% 17.2 pts better	Numerator 45 · Denominator 66
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 84 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	5.6%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 71 · Observed rate 1.41% · Lower 95% interval 2.67%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 140
Staff flu vaccination coverage	38.17%	42% 3.8 pts worse	Numerator 50 · Denominator 131
Discharge function score	71.21%	56.45% 14.8 pts better	Numerator 47 · Denominator 66
Transfer of health information to provider	98.46%	95.95% 2.5 pts better	Numerator 64 · Denominator 65
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.57%	25.2% 3.6 pts worse	Numerator 11 · Denominator 51

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
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	100.0%	93.5% 6.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	3.2% 1.7 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	9.5%	6.5% 3 pts worse	11.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 9.1% · Q4 25.8% · 4Q avg 9.5%
Percentage of long-stay residents who lose too much weight	3.2%	6.5% 3.3 pts better	5.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 4.2% · Q4 4.5% · 4Q avg 3.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.8%	19.9% 9.1 pts better	19.6% 8.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 12.5% · Q3 12.5% · Q4 9.5% · 4Q avg 10.8%
Percentage of long-stay residents who received an antipsychotic medication	11.6%	18.7% 7.1 pts better	16.7% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · 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	22.7%	19.6% 3.1 pts worse	16.3% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.7%	18.3% 7.6 pts better	14.9% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 9.1% · Q3 0.0% · 4Q avg 10.7% · 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	2.9%	1.7% 1.2 pts worse	1.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	35.5%	26.4% 9.1 pts worse	19.8% 15.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 52.6% · Q2 46.2% · Q3 24.5% · Q4 18.7% · 4Q avg 35.5%
Percentage of long-stay residents with pressure ulcers	4.0%	5.3% 1.3 pts better	5.1% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.5% · Q3 3.3% · Q4 1.3% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.9%	68.9% 31 pts better	81.7% 18.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.5% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit	9.1%	9.8% 0.7 pts better	12.0% 2.9 pts better	Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.8% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.7%	1.5% 1.2 pts worse	1.6% 1.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.8% · Q3 3.6% · Q4 3.9% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	90.9%	68.7% 22.2 pts better	79.7% 11.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	23.1% 4.8 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 23.8% · Expected 20.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-28 · Fire 2025-02-28

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-03-28 · Fire 2024-03-28

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-03-30 · Fire 2023-03-30

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-24

E · Potential for more than minimal harm 2024-03-28

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-04-18

C · Minimal harm 2024-03-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-18

F · Potential for more than minimal harm 2023-03-30

K521 · Services Deficiencies

Fire Safety

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

Corrected 2023-04-25

E · Potential for more than minimal harm 2023-03-30

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-04-25

E · Potential for more than minimal harm 2023-03-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-25

D · Potential for more than minimal harm 2023-03-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-25

C · Minimal harm 2023-03-30

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-04-25

C · Minimal harm 2023-03-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-04-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-03-24

E · Potential for more than minimal harm 2025-02-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-02-28

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-02-28

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-24

F · Potential for more than minimal harm 2024-03-28

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 2024-04-17

E · Potential for more than minimal harm 2024-03-28

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 2024-04-17

D · Potential for more than minimal harm 2024-03-28

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 2024-04-17

Penalties and ownership