Deficiency Records for Concord Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Concord Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2022-06-09 | 2022-07-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-09 | 2022-07-14 | 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 | 2022-06-09 | 2022-07-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-09 | 2022-07-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-09 | 2022-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-09 | 2022-07-14 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-06-09 | 2022-07-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-09 | 2022-07-14 | 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 | 2022-06-08 | 2022-07-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-08 | 2022-07-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-08 | 2022-07-08 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-21 | 2019-12-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-21 | 2019-12-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-21 | 2019-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-21 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-21 | 2019-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-21 | 2019-12-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-10-21 | 2019-11-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-11-12 | 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 | 2019-10-21 | 2019-11-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-21 | 2019-11-01 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-16 | 2018-10-09 | 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 | 2018-08-16 | 2018-10-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-16 | 2018-10-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-16 | 2018-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-16 | 2018-10-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-08-16 | 2018-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-16 | 2018-10-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-08-16 | 2018-10-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-16 | 2018-10-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-16 | 2018-10-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-16 | 2018-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-16 | 2018-10-04 | N |
