A list of the most recent deficiencies for Concordia Nursing and Rehab, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-27 | 2022-11-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-27 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-27 | 2022-11-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-24 | 2022-11-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-24 | 2022-11-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-27 | 2022-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-06 | 2021-08-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-06 | 2021-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-06 | 2021-08-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-06 | 2021-08-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-13 | 2021-08-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-13 | 2021-08-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-13 | 2021-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-13 | 2021-08-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-13 | 2021-08-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-13 | 2021-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-13 | 2021-08-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-13 | 2021-08-11 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-13 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-13 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-13 | 2021-08-11 | N |
| Keep all essential equipment working safely. | Health | 2021-07-13 | 2021-08-11 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-13 | 2021-08-11 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-21 | 2021-06-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-24 | 2020-03-06 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2020-01-24 | 2020-03-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-20 | 2020-03-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-24 | 2020-02-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-24 | 2020-02-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-24 | 2020-02-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-24 | 2020-02-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-24 | 2020-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-24 | 2020-02-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-24 | 2020-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-24 | 2020-02-23 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-24 | 2020-02-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-24 | 2020-02-23 | N |
