Deficiency Records for Concord Village Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Concord Village Skilled Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-30 | 2024-02-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-31 | 2023-04-12 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-17 | 2023-01-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-17 | 2023-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-17 | 2023-01-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-17 | 2023-01-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-23 | 2020-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-23 | 2020-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-23 | 2020-02-21 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-01-23 | 2020-02-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-01-23 | 2020-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-23 | 2020-02-21 | 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 | 2020-01-23 | 2020-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-23 | 2020-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-23 | 2020-02-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-23 | 2020-02-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-06 | 2018-12-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-06 | 2018-12-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-06 | 2018-12-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-12-03 | 2018-12-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-03 | 2018-12-24 | N |
