Cycle 1
Health 2025-02-28 · Fire 2025-02-28
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Baden, PA
Concordia At Villa St Joseph
1-star overall rating with 1-star inspections with $31,788 in total fines with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1030 State Street, Baden, PA
(724) 869-6300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Concordia Lutheran Ministries
Operator or chain grouping
Approved since
1997-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.12
Nurse aide staffing
Weekend hours
3.33
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
86.9%
12.2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
6.5%
4.4 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.1% |
6.5%
7.6 pts worse
|
5.4%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
19.9%
3.3 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
18.7%
10.2 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.0% |
19.6%
19.4 pts worse
|
16.3%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
18.3%
9.8 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
0.9%
2 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
26.4%
2.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.3%
1.4 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
68.9%
28.6 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.8%
About the same
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
68.7%
20.7 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.1%
3.7 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-03 · Fire 2023-05-03
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-07
D · Potential for more than minimal harm
2025-12-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-07
J · Immediate jeopardy
2025-02-28
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 2025-04-05
E · Potential for more than minimal harm
2025-02-28
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 2025-04-05
E · Potential for more than minimal harm
2025-02-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-02-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-02-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-02-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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 2025-04-05
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 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
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.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-05
D · Potential for more than minimal harm
2024-03-14
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 2024-04-24
D · Potential for more than minimal harm
2024-03-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-14
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 2024-04-24
D · Potential for more than minimal harm
2024-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-24
G · Actual harm
2023-10-26
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 2023-11-10
G · Actual harm
2023-10-26
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 2023-11-10
D · Potential for more than minimal harm
2023-10-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-03
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 2023-06-16
D · Potential for more than minimal harm
2023-05-03
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 2023-06-16
D · Potential for more than minimal harm
2023-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-16
Penalties and ownership
What sits behind the stars
$16,195
2025-02-28
Fine
Fine · fine $16,195
Fine
$7,796
2023-10-26
Fine
Fine · fine $7,796
Fine
$7,797
2023-10-26
Fine
Fine · fine $7,797
Fine
Ownership
Arnold, Rachelle
Operational/Managerial Control · Individual
Arnold, Rachelle
Corporate Director · Individual
Concordia Care Network
5% Or Greater Direct Ownership Interest · Organization
Falbo, Michael
Corporate Director · Individual
Falbo, Michael
Corporate Officer · Individual
Frndak, Keith
Corporate Director · Individual
Frndak, Keith
Corporate Officer · Individual
Grimenstein, Edward
Corporate Director · Individual
Hortert, Brian
Corporate Director · Individual
Hortert, Brian
Corporate Officer · Individual
Ricci, Phil
Corporate Director · Individual
Sullivan, Melissa
Corporate Director · Individual
Wolf, James
Corporate Director · Individual
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#2
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#3
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