Cycle 1
Health 2025-08-08 · Fire 2025-08-08
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cabot, PA
Concordia Lutheran Health And Human Care
2-star overall rating with 2-star inspections with $8,021 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
134 Marwood Road, Cabot, PA
(724) 352-1571
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
142
Certified beds
Average residents
136
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Concordia Lutheran Ministries
Operator or chain grouping
Approved since
1984-12-01
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
0.82
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.10
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
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.24
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,353
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.13% · Performance 24.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.25% · Performance 8.55% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.10
Baseline 27.97% · Performance 34.67% · Measure score 7.10 · Achievement 7.10 · Improvement 0
Adjusted total nurse staffing
2.46
Baseline 3.21 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 1.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.48% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 360 · Observed rate 12.5% · Lower 95% interval 9.43% |
| Discharge to community | 64.42% |
50.57%
13.9 pts better
|
Better than the National Rate · Eligible stays 334 · Observed rate 61.38% · Lower 95% interval 59.09% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 234 · Denominator 234 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 234 |
| Discharge self-care score | 56.02% |
53.69%
2.3 pts better
|
Numerator 107 · Denominator 191 |
| Discharge mobility score | 44.5% |
50.94%
6.4 pts worse
|
Numerator 85 · Denominator 191 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 6 · Denominator 234 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 8.56% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 198 · Observed rate 8.08% · Lower 95% interval 5.75% |
| Staff COVID-19 vaccination coverage | 0.31% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 325 |
| Staff flu vaccination coverage | 16.84% |
42%
25.2 pts worse
|
Numerator 50 · Denominator 297 |
| Discharge function score | 54.45% |
56.45%
2 pts worse
|
Numerator 104 · Denominator 191 |
| Transfer of health information to provider | 98.88% |
95.95%
2.9 pts better
|
Numerator 177 · Denominator 179 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.36% |
25.2%
7.8 pts worse
|
Numerator 21 · Denominator 121 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.2 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.2
1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
86.9%
11.1 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.5% · Q3 97.7% · Q4 97.8% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.8% |
93.5%
4.7 pts worse
|
95.5%
6.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 3.4% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
6.5%
4.3 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.2% · Q4 6.1% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.5%
2.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.7% · Q3 2.9% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
19.9%
6.7 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 29.9% · Q3 29.0% · Q4 21.7% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
18.7%
1 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 16.0% · Q3 20.0% · Q4 17.2% · 4Q avg 17.7% · 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 | 30.1% |
19.6%
10.5 pts worse
|
16.3%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q3 16.6% · Q4 36.3% · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
18.3%
1 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 18.5% · Q3 14.3% · Q4 25.8% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 0.8% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.5% |
26.4%
6.1 pts worse
|
19.8%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.8% · Q2 31.9% · Q3 24.8% · Q4 32.1% · 4Q avg 32.5% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.3%
0.5 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.2% · Q3 5.8% · Q4 3.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
68.9%
30.6 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.4% · Q3 99.6% · Q4 99.3% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.8%
3.8 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.5%
1.4 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
68.7%
20 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.5% |
23.1%
10.4 pts worse
|
23.9%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 28.3% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2023-10-20 · Fire 2023-10-20
9 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-25
C · Minimal harm
2025-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-25
B · Minimal harm
2025-08-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-08-25
B · Minimal harm
2025-08-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-08-25
F · Potential for more than minimal harm
2024-08-29
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-08-29
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-09-11
C · Minimal harm
2024-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-11
E · Potential for more than minimal harm
2023-10-20
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-08
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 2025-09-15
E · Potential for more than minimal harm
2025-08-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-08
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 2025-09-15
D · Potential for more than minimal harm
2025-08-08
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 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-08
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 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-08
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 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-15
C · Minimal harm
2024-09-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-08-29
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 2024-10-14
E · Potential for more than minimal harm
2024-08-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-29
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 2024-10-14
D · Potential for more than minimal harm
2024-08-29
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 2024-10-14
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-29
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 2024-10-14
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
J · Immediate jeopardy
2024-07-12
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 2024-07-24
D · Potential for more than minimal harm
2024-07-12
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-24
F · Potential for more than minimal harm
2023-10-20
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 2023-11-24
D · Potential for more than minimal harm
2023-10-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-20
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 2023-11-24
D · Potential for more than minimal harm
2023-10-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-20
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 2023-11-24
D · Potential for more than minimal harm
2023-10-20
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-20
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-07-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-07
Penalties and ownership
What sits behind the stars
$8,021
2024-07-12
Fine
Fine · fine $8,021
Fine
Ownership
Concordia Lutheran Ministries
5% Or Greater Indirect Ownership Interest · Organization
Beilstein, Karen
Operational/Managerial Control · Individual
Beilstein, Karen
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
Frndak-Suder, Kay
Corporate Director · Individual
Heintz, Frederick
Corporate Director · Individual
Hoffman, Paul
Corporate Director · Individual
Hortert, Brian
Corporate Director · Individual
Hortert, Brian
Corporate Officer · Individual
Ingram, Misty
Corporate Director · Individual
Young, Tammy
Corporate Director · Individual
Nearby options
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#2
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#3
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