Concordia Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to honor a resident's shower preferences for one resident (#4) of one sampled.Findings included: On 8/24/2025 at 10:00 a.m., an observation of Residents #4 revealed she was sitting in her bed. She expressed concerns related to her showers. Resident #4 stated she's been telling staff that she needs to have regular shower so she could feel like a normal person. Resident #4 said she gets bed baths, and they can't shower her. The resident did not know why the staff could not shower her.Review of Resident #4's progress note dated 8/15/2025 at 6:07 a.m. revealed .resident also stated she wants a shower due to not being offered one. states[sic] isn't she supposed to have a shower weekly. resident[sic] education on tuesday[sic] and friday[sic] schedule.A review of Residents #4 Admissions Record revealed an admission date of 5/23/2025 with diagnoses to include: multiple sclerosis, morbid (severe) obesity, type 2 diabetes, muscle wasting and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report allegations of abuse in a timely manner for two (#1 and #3) of two residents sampled for abuse and neglect. (Cross reference F600 and F610) Findings included: 1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury. Review of the admission Record for Resident #1 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified Dementia. An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/25 at 1:26 p.m. revealed she did not initiate the investigation for the incident on 03/22/25 until 03/27/25. She stated she could not answer to why staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to investigate thoroughly and timely allegations of abuse for two (#1 and #3) of two residents sampled for abuse and neglect. (Cross reference F600 and F609) Findings included: 1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury. Review of the admission Record for Resident #1 revealed he was originally admitted to the facility in 2013 and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified dementia. On 04/23/25 at 11:42 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) assigned to Resident #1 the day the resident fell on [DATE]. She stated she had worked 3 p.m. - 11 p.m. and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one (#1) of two residents sampled. Findings included: Review of a facility policy titled, Wound Prevention and Treatment Overview, effective October 2021 showed - The facility strives to ensure that a Resident/Patient entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements the following interventions to prevent the development of pressure ulcers: - Identify Residents/Patients at risk & the specific factors placing them at risk then implement an individualized Plan of Care based on the identified factors. - Reduce occurrence of pressure over bony prominences to minimize injury. - Protect against the adverse effects of external mechanical forces (pressure, friction, shear). - Increase the awareness of ulcer prevention through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation record review and interviews, the facility failed to ensure timely incontinence care and services were provided to promote Quality of Life for one (#2) of five sampled residents. Findings included: During a facility tour on 03/07/2025 at 9:29 a.m., Resident #2 was observed continuously calling for help. The resident continued calling for toileting from 9:29 a.m. to 9:58 a.m. and was observed to have waited approximately 30 minutes for bowel and incontinence care. On 03/07/2025 at 9:29 a.m., Resident #2 was heard calling out from her room, stating, Help me, Help. The resident's verbalization could be heard from the middle of the [NAME] hall. During the observation and interview of the resident in her room, Resident #2 was observed on a specialized mattress, and the covers pulled up to her shoulder. Resident #2 stated she needed help, she had messed herself. Resident #2 was heard to continue her cries for help and waiting to be assisted. On 03/07/2025 at 9:30 a.m., Staff A, Licensed Practical Nurse (LPN), was observed at the nursing station. When asked which aide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interviews, the facility failed to ensure timely repairs were completed for one of three air conditioning units and failed to ensure resident rooms were maintained in a safe and sanitary manner in two resident rooms (104 and 105) related to cracking, peeling, and dislodged ceiling material with discoloration. Findings included: An interview was conducted on 03/07/2025 at 10:52 a.m. with the Director of Maintenance (DOM). He stated one of the air conditioning (a/c) unit's main board were not working. He said there were three units on top of the building. The DOM said, the one that is not working has not been functioning for about one month, but we have a portable that has been in use. He stated the malfunction was determined on 01/28/2025. He stated he had obtained quotes which were submitted to corporate office. He said, At this time, we do not have approval for the work to be done. Review of an undated facility's maintenance log (electronic work system) listed a service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in six (105, 106, 109, 110, 111, and 112) out of eleven resident rooms and the medication room. Findings Included: During a facility tour on 5/7/24 at 9:30 a.m. the following observations were made: In room [ROOM NUMBER] there was a hole in the wall next to the resident's bed. Around the bed the wire mold was split and there were exposed wires. The base board next to the sink was separating from the wall. (Photographic Evidence Obtained). In room [ROOM NUMBER] there was a deep hole in the wall where the concrete infrastructure was observed next to the resident's bed. (Photographic Evidence Obtained). On 5/7/2024 at 9:40 a.m. during a tour of common areas and resident rooms, the following observations were made in resident rooms 109, 110, 111 and 112. Each room accommodated up to 4 residents, with a shared toilet and sink for up to eight residents. rooms [ROOM NUMBERS] and rooms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and review of the facility's policy Policy and Procedure: Topic Safety the facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Findings included: An observation on 05/07/24 at 9:30 a.m., revealed a two-door reach in refrigerator that had standing water sitting at the bottom of the refrigerator. There was a constant water drip coming from the top of the refrigerator. The water was observed dripping on a container of strawberries and then running off into the floor of refrigerator where standing water was present. Photographic evidence obtained. An observation on 05/07/24 at 9:35 a.m., revealed a sink that had a plastic cup with bottom cut out to fit over the faucet. The plastic cup sat over the bottom portion of the sink facet. A water drip was observed and continued to drip out of the faucet where the cup was placed. Photographic evidence obtained. An observation on 05/07/24 at 9:40 a.m., revealed a one-door reach in refrigerator that had standing water sitting at the bottom of the refrigerator.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident and resident representative received a bed hold notification prior to and upon transfer to the hospital for one (Resident #29) of two residents reviewed for bed hold notification. Findings included: Review of the admission Record for Resident #29 revealed an original admission date in January of 2024, a transfer to the hospital on [DATE], and a readmission to the facility on [DATE]. A review of the contact information revealed the resident's name and a second name labeled as Responsible Party/Health Care Proxy/and Emergency Contact #1. Review of a document titled, Health Care Proxy Designation and Acceptance Letter (FL) dated 01/12/24 confirmed the contact listed on the admission Record was the designated health care decision maker for Resident #29. Review of a document titled, BED HOLD AND IN-HOUSE TRANSFER POLICY, showed a form with Resident #29's name at the top. The area to list the Resident Representative's name was blank, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility's policy PASRR Requirements Level I & Level II, the facility failed to ensure seven (Residents #3, #5, #13, #18, #19, #20 and #26) of fourteen sample residents reviewed for PASRR screens had an accurate Level 1 Pre-admission Screening & Resident Review (PASRR). Findings included: 1. A review of the admission Record showed Resident #3 was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension, Major Depressive Disorder, Recurrent, Generalized Anxiety Disorder, Alzheimer's Disease and Persistent Mood [Affective] Disorder. Review of Resident #3's Level I PASRR not dated revealed, Section 1. Guide for determining an indication of a diagnoses of a serious mental illness- check those that apply showed Anxiety Disorder and Major Depression was not checked. A review of the admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses that included but not limited to Malignant Neoplasm of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accommodate resident preferences for activities based on assessments for two residents (#4, #13) of two residents sampled, related to not ensuring enough electrical outlets for an appliance (television) functionality. Findings included: 1. An interview on 03/07/2022 at 10:45 a.m. with Resident #4's Responsible Party stated they (the family) purchased the resident a television (TV) a few months ago for her room, however, is unsure what happened to it. An observation on 03/08/2022 at 10:04 a.m. revealed Resident #4 sitting upwards in a chair at bed side staring off with a blanket expression. The resident was alert with confusion. A TV was observed in the upper left corner at the base of the bed turned off. A review of Resident #4's admission Record revealed a medical diagnoses of muscle wasting, need for assistance with personal care, dementia in other diseases, and schizophrenia. A review of Resident #4's Care Plan revealed a focus area for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer blood pressure medications according to the physicians ordered blood pressure parameters for two residents (#2 and #33) of seven residents reviewed for unnecessary medications. Findings included 1) Review of Resident #2's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease and hypertension. Review of Resident #2's current physician orders revealed an order for Amlodipine Besylate tablet 5 milligrams (mg) give 1 tablet by mouth twice a day for hypertension. Hold for B/P (blood pressure) systolic <120 and or a diastolic <70. This order started on 7/18/2021 and was discontinued on 3/1/22. Review of the Resident #2's February 2022 Medication Administration Record (MAR) revealed she was administered Amlodipine Besylate 5 mg eight times when her blood pressure was not within the physicians' ordered parameters. On 2/8/22 at 9:00 a.m. the documented blood pressure (B/P) was 104/60,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to obtain a physician response and to implement orders related to pharmacy recommendations in a timely manner for one (#19) out of five residents sampled for unnecessary medications. Findings included: Resident #19 was interviewed on 3/2/21 at 12:37 p.m. while he was lying in bed after the noon meal. On 3/4/21 at 12:40 p.m., the resident was observed sitting on the front porch with supervision smoking a cigarette. Resident #19 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Chronic Obstructive Pulmonary Disease (COPD) and unspecified Peripheral Vascular Disease. The 5-day Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 6 out of 15 indicative of severe cognitive impairment. A review of a Pharmacy Recommendation for Resident #19, dated 12/5/20, indicated a recommendation that read, Resident has an order for Spiriva Inhaler. The normal dose for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.