A list of the most recent deficiencies for Concord Post Acute. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2023-12-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-16 | 2023-12-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-16 | 2023-12-16 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-16 | 2023-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-12-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-16 | 2023-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-20 | 2023-10-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-20 | 2023-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-12 | 2023-10-12 | Y |
| 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 | 2023-09-05 | 2023-09-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-12 | 2023-07-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-09 | 2023-03-09 | Y |
| Provide appropriate foot care. | Health | 2022-09-02 | 2022-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-07 | 2021-08-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-07 | 2021-08-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-07 | 2021-08-02 | 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 | 2021-05-07 | 2021-08-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-05-07 | 2021-08-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-08-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-07 | 2021-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-08-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-07 | 2021-08-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-07 | 2021-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-08-02 | N |
| Keep all essential equipment working safely. | Health | 2021-05-07 | 2021-08-02 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-05-18 | 2021-06-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-05 | 2019-05-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-04-05 | 2019-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-05 | 2019-05-05 | N |
| Post nurse staffing information every day. | Health | 2019-04-05 | 2019-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-05 | 2019-05-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-05 | 2019-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-05 | N |
