Cycle 1
Health 2025-04-04 · Fire 2025-04-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pittsburgh, PA
Concordia Of The South Hills
5-star overall rating with 4-star inspections with 1 recent health deficiencies
1300 Bower Hill Road, Pittsburgh, PA
(412) 278-1300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Concordia Lutheran Ministries
Operator or chain grouping
Approved since
2004-03-26
CMS approved date
Coverage
Medicare
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
1.06
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.34
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,895
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.49
Baseline 25.58% · Performance 22.16% · Measure score 3.49 · Achievement 0 · Improvement 3.49
Healthcare-associated infections
7.74
Baseline 7.02% · Performance 5.52% · Measure score 7.74 · Achievement 7.74 · Improvement 6.91
Total nurse turnover
2.19
Baseline 64.86% · Performance 54.72% · Measure score 2.19 · Achievement 2.19 · Improvement 2.04
Adjusted total nurse staffing
3.46
Baseline 4.75 hours · Performance 4.06 hours · Measure score 3.46 · Achievement 3.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 8.05% · Lower 95% interval 6.81% |
| Discharge to community | 61.26% |
50.57%
10.7 pts better
|
Better than the National Rate · Eligible stays 258 · Observed rate 59.69% · Lower 95% interval 55.84% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.87% |
95.27%
3.6 pts better
|
Numerator 175 · Denominator 177 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 177 |
| Discharge self-care score | 57.24% |
53.69%
3.6 pts better
|
Numerator 83 · Denominator 145 |
| Discharge mobility score | 69.66% |
50.94%
18.7 pts better
|
Numerator 101 · Denominator 145 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 177 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.52% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 2.4% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 0.93% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 107 |
| Staff flu vaccination coverage | 30.61% |
42%
11.4 pts worse
|
Numerator 30 · Denominator 98 |
| Discharge function score | 68.28% |
56.45%
11.8 pts better
|
Numerator 99 · Denominator 145 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 129 · Denominator 129 |
| Resident COVID-19 vaccinations up to date | 3.13% |
25.2%
22.1 pts worse
|
Numerator 3 · Denominator 96 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
6.5%
5 pts worse
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.5%
2.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
19.9%
3.9 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
18.7%
13.7 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.0% |
18.3%
18.3 pts better
|
14.9%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.9%
2.5 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
26.4%
2.9 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
5.3%
5.3 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · 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 99.7% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.8%
1.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.4% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
68.7%
22.4 pts better
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.1%
1.3 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.2% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-05-16 · Fire 2023-05-16
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-18
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-25
E · Potential for more than minimal harm
2024-04-18
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 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-14
D · Potential for more than minimal harm
2023-05-16
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 2023-06-20
D · Potential for more than minimal harm
2023-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-16
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 2023-06-20
Penalties and ownership
What sits behind the stars
Ownership
Concordia Care Network
5% Or Greater Direct Ownership Interest · Organization
Emert, Lori
Corporate Director · Individual
Falbo, Michael
Corporate Director · Individual
Falbo, Michael
Corporate Officer · Individual
Frndak, Keith
Corporate Director · Individual
Frndak, Keith
Corporate Officer · Individual
Frndak-Suder, Kay
Operational/Managerial Control · Individual
Frndak-Suder, Kay
Corporate Director · 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
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John J Kane Regional Center-Sc
Pittsburgh, PA
3-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Providence Point Healthcare Residence
Pittsburgh, PA
4-star overall rating with 3-star inspections with $13,575 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Asbury Health Center
Pittsburgh, PA
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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