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🔎 Concordia Lutheran Health And Human Care

Inspection Results


Inspection Overview

Concordia Lutheran Health And Human Care has been cited for a total of 35 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: C

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-09-12
Correction Date: 2024-10-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: 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.

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-08-29
Correction Date: 2024-10-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: J

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

Survey Date: 2024-07-12
Correction Date: 2024-07-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-07-12
Correction Date: 2024-07-24
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: 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.

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Observe each nurse aide's job performance and give regular training.

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-10-20
Correction Date: 2023-11-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-07-13
Correction Date:
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2022-10-20
Correction Date: 2022-11-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-10-20
Correction Date: 2022-11-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-10-20
Correction Date: 2022-11-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-10-20
Correction Date: 2022-11-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-10-20
Correction Date: 2022-11-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-10-22
Correction Date: 2021-12-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-10-22
Correction Date: 2021-12-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-10-22
Correction Date: 2021-12-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Dispose of garbage and refuse properly.

Survey Date: 2021-10-22
Correction Date: 2021-12-06
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-10-22
Correction Date: 2021-12-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-25
Correction Date: 2021-03-09
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2019-08-30
Correction Date: 2019-10-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-08-30
Correction Date: 2019-10-07
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**