Concordia at Villa St Joseph

In the surveyor’s words

From the most serious findings on record at Concordia at Villa St Joseph, in the surveyor’s own words.

• Immediate jeopardy, isolatedF726Feb 28, 2025

  Based 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). Findings include: Review of the [NAME] Life Vest Patient Manual updated 2021, indicated the following: Wear all day and all night Life Vest slides on and off like a backpack. If the garment fits loosely, call [NAME] (manufacturer). […]

• Actual harm, isolatedF600Oct 26, 2023

  Based 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). Findings include: Review of the facility Abuse, Neglect, and Exploitation policy dated 10/17/22, indicated it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. […]

• Actual harm, isolatedF689Oct 26, 2023

  Based 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). Findings include: Review of the facility Safe resident handling/Transfers policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents. […]

• Actual harm, isolatedF686Jul 29, 2022

  Based on review of facility policy, resident clinical record review, staff interviews, and family interview it was determined that the facility failed to provide care to prevent pressure ulcers, provide treatment and services necessary to promote healing and prevent infection of a pressure ulcer which all resulted in actual harm, the development of pressure ulcers and was a cause of death to one of five residents (Closed Record (CR) Resident R1). Findings include: Review of facility policy titled Wound Care Management Protocol last reviewed on 1/11/22, informed daily skin assessments are to be completed by the nurse and documented in the medical record when the patient has removable orthotic device or cast. […]

• No harm, potential for more than minimal, patternF677Jun 19, 2026

  Based 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).Findings include: Review of the facility policy Accessibility and Timely Response dated 1/1/26, indicated All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. During an observation of the Ebensburg Nursing Unit on 6/19/26, at approximately 11:15 a.m. multiple call lights were observed to be alarming, with both red and white lights illuminated above resident doors. […]