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Complaint Investigation

Concordia At Villa St Joseph

December 30, 2025 · Baden, PA · 1030 State Street
Citations 2
CMS Rating 2/5
Beds 120
Provider ID 396026
Healthcare Facility
Concordia At Villa St Joseph
Baden, PA  ·  View full profile →
Inspection Summary

CONCORDIA AT VILLA ST JOSEPH in BADEN, PA — inspection on December 30, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of the facility policy Incident and Accidents last reviewed 1/2/25, indicated injuries will be assesses by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so.

Review of Employee counseling reports dated 11/17/25, indicated two Nurse Aids (NA) were re-educated on residents that have a fall will require an evaluation from a Registered Nurse (RN) prior to assisting that resident into a bed or chair.

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine).

Interview completed on 12/20/25, at 11:25 a.m. upon asking Resident R1 concerning a fall that occurred in November he stated I was getting ready for bed, I used a walker, I stood up grabbed my walker went to pivot and I just kind of slumped down, the aid was by me, I went down slow not hard, just slowly on my left side she made sure I was alright and went and got another aide they used the lift to get me back in bed.

Review of facility investigative report and nursing notes on 12/20/25, indicated Resident R1 had a fall on 11/15/25, Resident R1 was returned to bed utilizing a mechanical lift by two NA's the notes failed to include notification to the Registered Nurse (RN) or practitioner for assessment of injury prior to returning Resident R1 to bed.

Interview completed on 12/30/25, at 12:40 p.m. the Director of Nursing confirmed 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). 28 Pa.

Code 201.18 (b)(1) Management. 28 Pa.

Code 211.10 (c)(d) Resident Care policies. 28 Pa.

Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia at Villa St Joseph

1030 State Street Baden, PA 15005

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine).

Section H0100 indicated indwelling foley catheter use.

Review of Resident R1's physician order dated 9/30/25, indicated to change suprapubic catheter every four weeks the order failed to include specifications for size and balloon inflation amount for the suprapubic catheter.

Review of Resident R1's care plan with revision on 12/18/25, indicated suprapubic catheter use and failed to include specifications for size and balloon inflation amount for the suprapubic catheter.

Interview completed on 12/30/25, the Director of nursing confirmed the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter and balloon inflation amount for one of three residents (Resident R1). 28 Pa.

Code 201. 18(b)(1) Management.28 Pa code:211.10(c)(d) Resident care policies.28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BADEN, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CONCORDIA AT VILLA ST JOSEPH or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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