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
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
0.81
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,634
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.36
Baseline 22.08% · Performance 20.13% · Measure score 3.36 · Achievement 2.8 · Improvement 3.36
Healthcare-associated infections
3.69
Baseline 5.78% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
6.66
Baseline 41.61% · Performance 36.44% · Measure score 6.66 · Achievement 6.66 · Improvement 2.58
Adjusted total nurse staffing
1.95
Baseline 3.91 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 9.45% · Lower 95% interval 7.29% |
| Discharge to community | 60.99% |
50.57%
10.4 pts better
|
Better than the National Rate · Eligible stays 192 · Observed rate 58.33% · Lower 95% interval 55.13% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.76% |
95.27%
2.5 pts better
|
Numerator 131 · Denominator 134 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 134 |
| Discharge self-care score | 46.85% |
53.69%
6.8 pts worse
|
Numerator 52 · Denominator 111 |
| Discharge mobility score | 41.44% |
50.94%
9.5 pts worse
|
Numerator 46 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 2.24% |
2.29%
About the same
|
Numerator 3 · Denominator 134 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 5.22% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 0.37% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 271 |
| Staff flu vaccination coverage | 23.05% |
42%
18.9 pts worse
|
Numerator 59 · Denominator 256 |
| Discharge function score | 53.15% |
56.45%
3.3 pts worse
|
Numerator 59 · Denominator 111 |
| Transfer of health information to provider | 99.03% |
95.95%
3.1 pts better
|
Numerator 102 · Denominator 103 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.21% |
25.2%
3 pts better
|
Numerator 22 · Denominator 78 |
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 · Q1 100.0% · Q2 96.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 1.9% · Q3 3.7% · Q4 4.0% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 6.0% · 4Q avg 2.1% |
| 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 · Q1 7.7% · Q2 15.2% · Q3 19.6% · Q4 14.6% · 4Q avg 14.1% |
| 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 · Q1 19.2% · Q2 15.2% · Q3 14.9% · Q4 16.7% · 4Q avg 16.6% |
| 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 · Q1 6.8% · Q2 2.9% · Q3 8.1% · Q4 15.8% · 4Q avg 8.5% · 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 | 39.0% |
19.6%
19.4 pts worse
|
16.3%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.0% · Used in QM five-star |
| 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 · Q1 34.0% · Q2 31.0% · Q3 14.0% · Q4 33.3% · 4Q avg 28.1% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 1.6% · Q3 2.3% · Q4 6.9% · 4Q avg 2.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 3.8% · Q3 1.9% · Q4 4.1% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 36.7% · Q2 14.1% · Q3 31.6% · Q4 33.7% · 4Q avg 29.2% |
| 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 · Q1 5.0% · Q2 4.3% · Q3 2.2% · Q4 4.0% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 94.8% · Q2 96.9% · Q3 99.0% · Q4 99.5% · 4Q avg 97.5% |
| 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 · Adjusted 9.8% · Observed 9.8% · Expected 11.1% · Used in QM five-star |
| 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 · Q1 1.3% · Q2 1.6% · Q3 1.8% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| 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 · 4Q avg 89.4% |
| 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 · Adjusted 19.4% · Observed 17.9% · Expected 22.0% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Beaver Healthcare And Rehabilitation Center
Aliquippa, PA
1-star overall rating with 1-star inspections with abuse icon flag with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Rochester Residence And Care Center
Rochester, PA
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $353,716 in total fines with 49 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Brighton Rehabilitation and Wellness Center
Beaver, PA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $234,389 in total fines with 63 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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