CONCORDIA LUTHERAN HEALTH AND HUMAN CARE Nursing Home


CONCORDIA LUTHERAN HEALTH AND HUMAN CARE (CCN: 395684) is a Non profit - Corporation facility located in CABOT, PA (16023). The facility has an overall rating of 3/5, health inspection rating of 3/5, and a staffing rating of 2/5. It offers 142 certified beds and maintains an average of 136. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.44427 total hours per resident per day. It has been certified since December 1, 1984 and the last listed health inspection was on October 20, 2023, The facility is located in Butler county and provides senior and nursing home care.

CONCORDIA LUTHERAN HEALTH AND HUMAN CARE Summary


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Provider Name: CONCORDIA LUTHERAN HEALTH AND HUMAN CARE

Address: 134 MARWOOD ROAD, CABOT, PA 16023

Phone: (724) 352-1571

County: Butler (150)

Ownership Type: Non profit - Corporation

Certified Beds: 142

Average Residents Per Day: 136. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: CONCORDIA LUTHERAN HEALTH AND HUMAN CARE

First Approved Date: December 1, 1984

Affiliated Entity: CONCORDIA LUTHERAN MINISTRIES (573)

Retirement Community: Y, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 3 ()

Health Inspection Rating: 3 ()

QM Rating: 4 ()

Long Stay QM Rating: 4 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.95027, LPN Staff Hours Per Day: 1.0348, RN Staff Hours Per Day: 0.4591, Licensed Staff Hours Per Day: 1.4939

Total Nurse Staff Hours Per Day, per resident: 3.44427

Weekend Nurse Staff Hours: 2.84819, Weekend RN Staff Hours: 0.3289

PT Staff Hours Per Day, per resident: 0.0931

Nurse Staff Turnover: 33.8, Nurse Turnover Note:

RN Turnover: 58.8, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.3809, Case Mix LPN Hours Per Day: 0.7766, Case Mix RN Hours Per Day: 0.4240

Adjusted Nurse Aide Hours Per Day, per resident: 1.66873, Adjusted LPN Hours Per Day: 0.9833, Adjusted RN Hours Per Day: 0.4079

Total Adjusted Nurse Hours Per Day, per resident: 3.03107

Adjusted Weekend Nurse Hours Per Day, per resident: 2.50650

Health Survey Dates and Scores: Cycle 1: 2023-10-20 (Score: 48), Cycle 2: 2022-10-20 (Score: 36), Cycle 3: 2021-10-22 (Score: 24)

Total Weighted Health Score: 40.000

Reported Incidents: 0, Substantiated Complaints: 0

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 3250.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 134 MARWOOD ROAD,CABOT,PA,16023 (40.7740, -79.786)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-13

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2023-10-20

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

Type: Health, Deficiency: Observe each nurse aide's job performance and give regular training.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2023-10-20

Type: Health, Deficiency: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-24

Citation on 2022-10-20

Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-29

Citation on 2022-10-20

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

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-29

Citation on 2022-10-20

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-29

Citation on 2022-10-20

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-29

Citation on 2022-10-20

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-29

Citation on 2021-10-22

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-06

Citation on 2021-10-22

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-06

Citation on 2021-10-22

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-06

Citation on 2021-10-22

Type: Health, Deficiency: Dispose of garbage and refuse properly.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-06

Citation on 2021-10-22

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-06


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-10-19

Type: Fire Safety, Tag: 0754, Version: New

Description: Provide properly sized and located linen or trash receptacles.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-13

Citation on 2023-10-19

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-11-13

Citation on 2022-10-25

Type: Fire Safety, Tag: 0100, Version: New

Description: Meet other general requirements.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-18

Citation on 2022-10-25

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-18

Citation on 2021-10-25

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-03

Citation on 2021-10-25

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-03

Citation on 2021-10-25

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-03