Concordia Village Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform hand hygiene prior to donning gloves and in between glove changes, failed to wear gloves while touching resident food, and failed to change gloves and perform hand hygiene when providing incontinent care for 6 of 8 (R1, R2, R17, R33, R37, R41) residents, reviewed for infection control in a sample of 34. Findings include:1.On 01/05/2026 at 11:45 AM, V6, (Certified Nurse Assistant) CNA, donned gloves, without benefit of hand hygiene, served lunch meal to a resident, then she removed her gloves, opened the refrigerator with her bare hands, took out ketchup, closed the refrigerator door and returned to the table, dispensed ketchup, and returned it to the counter. She then took another pair of gloves and donned them without benefit of hand hygiene. She then delivered a meal tray to R37 and set up her meal tray for her. 2.On 01/05/2026 at11:56 AM, V7, CNA, donned a pair of gloves without benefit of hand hygiene, and delivered meal tray…

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 interview and record review, the facility failed to ensure residents were free from verbal abuse from staff for 1 of 3 residents (R31) reviewed for abuse in the sample of 34. Findings Include:R31's Face Sheet, print date of 1/5/26, documented R31 has diagnoses including Parkinson's disease, dementia, visual hallucinations, aphasia, and dysphagia.R31's MDS (Minimum Data Set) documented R31 is severely cognitively impaired and is dependent on staff for mobility. R31's care plan, print date of 1/5/26, documented R31 has a diagnosis of anxiety disorder with physical manifestations of hallucinations with interventions including touch hands/shoulder to show caring or provide comfort. Provide 1-1 interaction. The Facility's IDPH (Illinois Department of Public Health) Notification form, dated 11/21/25, documented date of alleged incident: 11/8/25 and 11/11/25, General Category: Resident verbal abuse, Name of Resident: (R31), Mental Status: Alert and oriented X1. It continues, during the process of investigation, medical record review and interview of witnesses, etc., the following…

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, observation, and record review, the facility failed to implement fall interventions for 2 out of 6 residents (R4, R46) in a sample of 34 reviewed for Quality of Care. Findings include:1.R4's Facesheet documented she was admitted to the facility on [DATE] with diagnoses of dysphasia, drug induced Parkinsonism, and chronic obstructive pulmonary disease.R4's Minimum Data Set (MDS), dated [DATE], documented she was severely cognitively impaired and was dependent on staff to roll in bed and for chair/bed to chair transfers. The MDS also documented they could not complete transfers involving sit to lying, lying to sitting, sit to standing, toilet, or shower due to R4's current illness, exacerbation or injury.R4's Care Plan, dated 1/24/22, documented she is a risk for falls with interventions of: on 1/28/22 provide body pillow while in bed; on 10/19/23 fall mat in place next to bed; on 8/21/25 fall body pillow (already implemented on 1/28/22) to assist resident comfortably on her side to help with…

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, interview, and record review the facility failed to provide complete incontinent care for 1 of 2 (R2) residents reviewed for incontinent care in a sample of 34. Findings Include:R2's Face Sheet, print date of 1/7/26, documented R2 has diagnoses including urinary tract infection, Parkinson's disease, aphasia following cerebral infarction, and hypertensive heart disease with heart failure.R2's MDS (Minimum Data Set), dated 11/17/25, documented R2 is severely cognitively impaired.R2's Care Plan Report, print date of 1/8/26, documented R2 has ADL (activities of daily living) selfcare deficit related to decreased mobility and muscle weakness. R2's Care Plan also documented R2 is occasionally incontinent. On 1/6/26 at 11:35 AM, V15, CNA (Certified Nurse Assistant), donned gloves without completing hand hygiene prior to donning the gloves. V15 removed R2's adult diaper that was soiled with a small amount of feces. V15 then cleansed R2's inner thighs on both sides then turned R2 onto her right side and began cleansing R2's buttock. V15 did not cleanse R2's inner…

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 transcribe and follow the physician's orders for 1 of 5 (R1) reviewed for physician orders in the sample of 34. The findings include:R1's Facesheet, dated 1/6/26, documents R1 was admitted on [DATE] with diagnoses of Aortic Valve replacement, Pulmonary emboli and fibrosis, Atrial Fibrillation, Atherosclerotic heart disease, Diabetes Mellitus Type 2, Malignant neoplasm of bronchus or lung, Benign Prostatic Hyperplasia (BPH), Depression, and Chronic Obstructive Pulmonary Disease. R1's Care Plan, dated 12/24/25, documents R1 is on an anticoagulant and is at risk for bleeding. R1 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence, mobility, balance. R1 has Activities of Daily Living (ADL) selfcare deficit related to decreased mobility and muscle weakness. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires partial/moderate assistance from staff 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, observation, and record review, the facility failed to serve food at a safe and appetizing temperature for 1 out of 1 resident (R37) reviewed for Food and Nutrition Services in a sample size of 34.Findings include:R37's Facesheet documented she was admitted to the facility on [DATE], with diagnoses of quadriplegia, anxiety disorder, and malaise. R37's Minimum Data Set (MDS), dated [DATE], documented R37 was cognitively intact.On 1/6/26 at 10:30 AM, R37 stated, I live in one of the last rooms on the hall and the food is not the warmest; isn't cold but could be warmer.On 1/6/26 at 11:34 AM, lunch temperatures off the steam table were recorded in degrees Fahrenheit go as follows: seafood crepe: 185 degrees, quiche: 145 degrees, potato wedges: 145 degrees.On 1/6/26 at 12:15 PM, the test tray after all residents were served was temperature checked and the following food was recorded in degrees Fahrenheit: seafood crepe:129.5 degrees, quiche was 131 degrees, and the potato wedges were 123.4…

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 interview, observation, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety by not performing hand hygiene and glove changes while serving food to 2 of 10 residents (R1, R17) reviewed for serving food sanitarily in the sample of 34.The findings include: On 1/5/26 at 12:00 PM during lunch observation in the kitchenette on the hall, V11, Cook, was seen putting a pair of blue gloves on after bringing up the warming cart; no hand hygiene seen. V11 kept the same pair of gloves on during the following: getting plates of food from warmer, removing lids and plastic wrap from food, had tongs in one hand and then with the other, grabbed some lettuce, onions, and tomato slices with his hand instead of using the tongs. V11 was seen opening cabinets, the fridge, running the mixer/blender, and touching everything in the kitchenette. V11 was also seen rinsing dishes in the sink, wrapping and putting away food items in the fridge, wiping the counters off, then would get another resident's plate ready, including…

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 interview, observation, and record review, the facility failed to label and date food products, restrain hair, and ensure resident use refrigerators are only used for residents to prevent foodborne illness. This failure has the potential to affect all 51 residents residing at the facility. Findings include: On 8/19/24 at 10:30 AM, the main kitchen was observed. The walk in refrigerator had a container of meat (which appeared to be tuna). The container was not labeled or dated. The main kitchen freezer had a metal sheet pan lying on the floor. There was a frozen bag with red pasta sauce on the sheet pan. At 10:40 AM, the Summer hall kitchen refrigerators were observed. The was an employee lunch box, 3 premade salads, a storage container of cottage cheese, a storage container of what appears to be tartar sauce. None were labeled or dated with made on and expires on dates. There were 9 fruit cups and 9 applesauce cups that were not covered, labeled or dated. The freezer section had frozen meat that was not labeled or dated, an open storage bag of frozen waffles, and breakfast…

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 interview, observation, and record review, the facility failed to dispose of medications for 2 of 51 residents (R42, R115) reviewed for medication storage in the sample of 29. Findings include: 1. On 8/20/24 at 8:55 AM, reviewed medication storage room with V7, Licensed Practical Nurse (LPN). In the medication refrigerator there were 3 Lantus Pens and a vial of 100 units for R155. V7 stated R155 has not been in the facility for awhile. V7 stated, Old medications are destroyed. Our pharmacy never accepts medications for refund. R155's Face Sheet, print date of 8/22/24, documents R155 was discharged on 5/7/24. On 8/20/24 at 9:08 AM, the (hall name) medication storage room was observed. R42 had 5 prescription cards stored; Potassium Chloride 20 meq (milliequivalent) ER (extended release) dispense date of 4/18/24, Ocuvite tablets dispense date of 4/15/24, Rosuvastatin 40 mg (milligrams) dispense date of 4/24/24, Acetaminophen 325 mg (milligrams), dispense date 2/22/24, and Losartan 25 mg dispense date of 4/26/24. R42's Census Record, undated, documents R42 was moved from (hall…

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 interview, observation, and record review, the facility failed to perform hand hygiene, post a needed isolation sign, and use Personal Protective Equipment (PPE) for 2 of 24 residents (R40, R255) reviewed for infection control in sample of 29. Findings include: 1. On 8/20/24 at 8:37 AM, V7, Licensed Practical Nurse, LPN, gave R40 his pill medication to take. R40 took all the medications. V7 donned gloves with no hand hygiene before, and then administered eye drops in R40's eyes. On 8/22/24 at 11:15 PM, V2, Director of Nursing, DON, stated hand hygiene should be done before donning gloves. The policy Hand Hygiene, dated 1/30/24, documents, 1. Perform hand hygiene before applying non - sterile gloves. 2. On 8/20/24 at 1:00 PM, V2 stated, (R255) just turned positive with COVID. On 8/21/24 at 8:45 AM, R255's door does not have an isolation and needed PPE sign on the door. On 8/21/24 at 8:50 AM, V2 stated ]R255 should have a signage indicating what personal protective equipment is need. R255's Clinical Note, dated 8/20/24, documents, Resident was tested for COVID via POC (Point…

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 secure medications appropriately, and failed to label and date open bottles of medications. The facility also failed to ensure medications requiring refrigeration were monitored and documented per the Facility policy. This has the potential to affect all 49 residents living in the facility. Findings include: 1. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams, (mg)-timolol 6.8 mg/milliliters, (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, the rehabilitation hall medication cart was in the hallway and was unlocked. V5, Registered…

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 complete incontinence care for 4 of 4 (R6, R19, R36, R41) residents reviewed for incontinent care in a sample of 13. Findings include: 1. R6's Care Plan, last evaluation date 9/19/23, documents R6 is always incontinent of urine and frequently incontinent of bowel. It also documents, check for incontinence; clean and dry skin if wet or soiled. R6's Minimum Data Set/MDS, dated [DATE], documents R6 is severely cognitively impaired, always incontinent of bowel and bladder, and is totally dependent on 2 staff for toileting. On 9/19/2023 at 1:40 PM, V11, V13, and V16, all CNAs (Certified Nursing Assistants), assisted R6 with incontinent care. V11, V13, and V16 transferred R6 into the bed using the full body lift. V11, V13, and V16 rolled R6 onto his left side and removed his pants, then assisted to R6 to R6's back. V16 opened R6's incontinent brief. V11, V13, and V16 turned R6 onto his right side, and V16 removed R6's incontinent brief…

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 perform appropriate hand hygiene and donning gloves during medication administration and incontinent care and, and failed to perform appropriate cleaning of soiled surfaces for 4 of 6 (R31, R101, R102 R104) residents reviewed infection prevention, in a sample of 28. Findings include: 1.R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented his cognition was moderately impaired. R104's Physician Order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams (mg)-timolol 6.8 mg/milliliters (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, V5, Registered Nurse, (RN), statedshe spilled Metamucil granules on top of the medication cart. V5 retrieved a dry paper…

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.