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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-01 | 2024-02-29 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2024-02-01 | 2024-02-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-01 | 2024-02-29 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-01 | 2024-02-29 | 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 | 2024-02-01 | 2024-02-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-01 | 2024-02-29 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-01 | 2024-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-02-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-02-01 | 2024-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | 2024-02-29 | 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 | 2024-01-29 | 2024-02-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-29 | 2024-02-27 | N |
| 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 |
