Care Citations

CONCORDIA AT VILLA ST JOSEPH

1030 STATE STREET, BADEN, PA, 15005 · 7248696300

On the CMS record

Overall rating (CMS)
2 / 5
Health inspection rating
2 / 5
Staffing rating
4 / 5
Certified beds
120
Ownership type
Non profit - Corporation
Chain
CONCORDIA LUTHERAN MINISTRIES

Inspection findings on record (43)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity E · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0605 · scope/severity E · potential for more than minimal harm

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity E · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0694 · scope/severity D · potential for more than minimal harm

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity B · potential for minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity J · immediate jeopardy

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0622 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0908 · scope/severity E · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity D · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0849 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity G · actual harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 396026