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Home / Pennsylvania / Baden

Concordia at Villa St. Joseph

1030 State Street, Baden, PA 15005 · Beaver County · (724) 869-6300

120 certified beds, about 113 residents a day · Non profit - Corporation · Medicare and Medicaid since 1997

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 396026 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on March 5, 2026, inspectors cited 12 health deficiencies (the Pennsylvania average is 10, the national average 9.2).

Of 43 health citations since October 2023, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 3 fines totaling $31,788 in the last three years; the largest was $16,195, and the latest is dated February 28, 2025.

Nurses and nurse aides worked 3.79 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.89 of those hours.

26.2% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).

CMS links it to Concordia Lutheran Ministries, an affiliated group of 8 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
30D
9E
0F
Potential for minimal harm
0A
1B
0C
June 19, 2026Complaint inspection · 1 citation
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 3, 2026
    Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide activity of daily living assistance for six of 29 residents (Resident R1, R2, R3, R4, R5, and R6).
March 5, 2026Standard inspection · 12 citations
  1. E
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for three of five sampled residents (Residents R2, R8, and Resident R9).
  2. E
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for five of eight residents reviewed (Resident R21, R28, R147, and R157).
  3. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for three of four residents (Resident R36, R73, R157).
  4. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, and facility documents and staff and resident interviews it was determined that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for one of five residents (Resident R142).
  5. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy and facility documents, clinical records, staff and family interviews it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of one of four abuse allegations (Resident R74).
  6. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, facility documents, clinical records, and staff interview it was determined that the facility failed to conduct a thorough investigation of an injury of unknown origin to eliminate possible neglect for one of four residents (Resident R74).
  7. D
    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.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff and resident interviews, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents reviewed (Residents R147).
  8. D
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    F694 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, clinical records, staff interviews, and resident observations it was determined that the facility failed to maintain a peripheral intravenous (IV) catheter site consistent with professional standards of practice for one of three residents (Resident R29).
  9. D
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, clinical records, and staff and resident family interviews it was determined that the facility failed to meet residents pain needs for two of two residents reviewed (Resident R5 and Resident R159).
  10. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three medication rooms. (Fontbonne Medication Room).
  11. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly clean and disinfect a contact isolation room with the appropriate disinfectant for one of three residents (Resident R21).
  12. B
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2026
    Inspectors wroteBased on review of facility documentation, resident and staff interviews it was determined that the facility failed to observe resident rights for four of four residents.
December 30, 2025Complaint inspection · 2 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 7, 2026
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1).
  2. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 7, 2026
    Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter (a thin, flexible tube inserted into the bladder through a small hole in the lower belly to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R1).
February 28, 2025Standard inspection, Complaint inspection · 19 citations
  1. J
    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.
    F726 · Nursing and Physician Services · Immediate jeopardy to resident health or safety, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on manufacturer's instructions, clinical record reviews, and staff interviews it was determined that the facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed two of two residents in immediate jeopardy in which health and safety were impacted (Resident R314, and R49).
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of observations and staff interview, it was determined that the facility failed to provide a dignified dining experience for one of three unit dining rooms observed. (Carondelet Resident R14), and failed to protect and value residents' private space ([NAME] Resident R110, R215, and Fontbonne Resident R8)
  3. E
    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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Residents R29, R70, R75, Closed Resident Record CR265, and Closed Resident Record CR266).
  4. E
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R29, R70, R75, Closed Resident Record CR265 and Closed Resident Record CR266).
  5. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of ten residents (Resident R49, R228, and R314).
  6. E
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three crash carts.
  7. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of clinical record, and staff interview, it was determined that the facility failed to develop a baseline care plan that included Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death) interventions needed to provide effective and person-centered care for two of ten residents (Resident R49 and R314).
  8. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of seven residents (Resident R70 and R90) to accurately reflect the current status of the resident.
  9. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on observation, clinical record review and staff interview it was determined that the facility failed to clarify a physician's order for four of seven sampled residents (Resident R49, R57, R70, and R314).
  10. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R35, and Closed Resident Record CR265).
  11. D
    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.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Residents R90).
  12. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to obtain a complete order for a resident with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), failed to obtain a physician order for use of a CPAP machine (a form of non-invasive ventilation (NIV) therapy used to facilitate breathing), and failed to develop a plan of care for two of five residents (Resident R90 and Closed Resident Record CR264).
  13. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of resident clinical records and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R165) for two of four days.
  14. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for one out of three residents (Resident R75).
  15. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of three medication carts (Ebensburg Second Hall Med Cart).
  16. D
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff had the specific competencies and skill set necessary to provide care for residents with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death).
  17. D
    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.
    F838 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.
  18. D
    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.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to identify a hospice provider in physician orders and failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of three residents (Residents R59 and R90).
  19. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 5, 2025
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of two residents (Resident R8).
March 14, 2024Standard inspection, Complaint inspection · 6 citations
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were free from verbal abuse for one of three residents (Resident R50).
  2. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two out of five sampled resident records (Residents R76 and R80).
  3. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for one of four residents (Resident R2) with an indwelling catheter (a tube inserted in the bladder to drain urine).
  4. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of five residents reviewed (Resident R2 and R315).
  5. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts and failed to properly secure medications and/or biologicals for two of six residents.
  6. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 24, 2024
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly disinfect reusable equipment between residents for one of four nursing units observed ([NAME] Unit) and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R85).
October 26, 2023Complaint inspection · 3 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2023
    Inspectors wroteBased on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility neglected to provide the appropriate device to prevent a fall while staff was transporting a resident in a wheelchair, that resulted in actual harm of a head injury for one of four residents (Resident R1).
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2023
    Inspectors wroteBased on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a head injury for one of four residents reviewed (Resident R1).
  3. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2023
    Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident CR1).

Fire safety inspections

10 fire safety citations on file: 2 on March 5, 2026, 4 on February 28, 2025, 4 on March 14, 2024.

Every fire safety citation10 citations
  1. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · March 5, 2026 · Corrected (the home has a date of correction)
  2. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 5, 2026 · Corrected (the home has a date of correction)
  3. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · February 28, 2025 · Corrected (the home has a date of correction)
  4. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 28, 2025 · Corrected (the home has a date of correction)
  5. E
    Ensure proper usage of power strips and extension cords.
    K 920 · February 28, 2025 · Corrected (the home has a date of correction)
  6. E
    Have proper medical gas storage and administration areas.
    K 923 · February 28, 2025 · Corrected (the home has a date of correction)
  7. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · March 14, 2024 · Corrected (the home has a date of correction)
  8. E
    Provide properly protected cooking facilities.
    K 324 · March 14, 2024 · Corrected (the home has a date of correction)
  9. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 14, 2024 · Corrected (the home has a date of correction)
  10. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · March 14, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 28, 2025Fine $16,195
October 26, 2023Fine $7,796
October 26, 2023Fine $7,797

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homePennsylvaniaUnited States
All nursing staff (RN, LPN and aides)3.793.893.86
Registered nurses0.890.790.69
All nursing staff on weekends3.453.533.42
Nurse aides2.16
Licensed practical nurses0.74
Nursing staff turnover (share who left in a year)26.2%44.5%45.8%
Registered nurse turnover22.7%39.9%42.9%
Administrators who left0

CMS expects 4.13 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.93 on weekdays and 3.45 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.70 in April to June 2025 to 3.79 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.790.893.933.45 0.0%0 of 90113
Oct to Dec 20253.880.874.013.53 0.0%0 of 92110
Jul to Sep 20253.640.813.763.33 0.0%0 of 92112
Apr to Jun 20253.700.863.833.36 0.0%0 of 91112
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Pennsylvania, Jan to Mar 20263.690.653.823.3411.3%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homePennsylvaniaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
23.816.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
3.60.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
3.31.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.33.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
2.11.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
43.017.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.84.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
15.417.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
22.622.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
15.69.512.0

Owners and operators

Legal business name: CONCORDIA LUTHERAN MINISTRIES OF PITTSBURGH. CMS links this home to Concordia Lutheran Ministries, a group of 8 nursing homes averaging 3.8 stars overall.

NameRoleTypeShareSince
Concordia Care Network5% or greater direct ownership interestOrganization09/01/2022
Arnold, RachelleCorporate directorIndividual04/26/2018
Falbo, MichaelCorporate directorIndividual01/01/2020
Frndak, KeithCorporate directorIndividual04/26/2018
Grimenstein, EdwardCorporate directorIndividual04/26/2018
Hortert, BrianCorporate directorIndividual04/26/2018
Ricci, PhilCorporate directorIndividual01/01/2022
Sullivan, MelissaCorporate directorIndividual01/01/2022
Wolf, JamesCorporate directorIndividual01/01/2022
Falbo, MichaelCorporate officerIndividual01/01/2019
Frndak, KeithCorporate officerIndividual04/26/2018
Hortert, BrianCorporate officerIndividual04/26/2018
Arnold, RachelleOperational/managerial controlIndividual04/26/2018
Arnold, RachelleAdp of the SNFIndividual04/26/2018
Falbo, MichaelAdp of the SNFIndividual01/01/2019
Frndak, KeithAdp of the SNFIndividual04/26/2018
Hortert, BrianAdp of the SNFIndividual04/26/2018
Oster, MarcAdp of the SNFIndividual04/01/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 15 problems in this area, most recently on June 19, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  2. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 6 problems in this area, most recently on March 5, 2026: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function."
  3. When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on March 5, 2026: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
  4. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on March 5, 2026: "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."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.45 hours per resident per day, below the Pennsylvania average of 3.53.

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Common questions

What is Concordia at Villa St. Joseph's Medicare star rating?
CMS rates Concordia at Villa St. Joseph 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Concordia at Villa St. Joseph get at its last inspection?
12 health deficiencies at the standard inspection on March 5, 2026. The Pennsylvania average is 10.
Has Concordia at Villa St. Joseph been fined?
Yes. CMS lists 3 fines totaling $31,788 in the last three years.
Does Concordia at Villa St. Joseph accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Concordia at Villa St. Joseph?
CMS lists 18 owners and managers, and links the home to Concordia Lutheran Ministries. Legal business name: CONCORDIA LUTHERAN MINISTRIES OF PITTSBURGH.

Sources

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