Care One at Concord

In the surveyor’s words

From the most serious findings on record at Care One at Concord, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 7, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a mechanical lift with the assistance of two staff members for transfers later during the day or when he/she was fatigued or in pain, the Facility failed to ensure he/she was provided with an adequate level of safety from staff while being transferred via the mechanical in an effort to maintain his/her safety to prevent an incident/accident resulting in an injury. On 09/29/23, two Certified Nurse Aides (CNA's) attempted to transfer Resident #1 from a shower chair into his/her bed with the use of a mechanical lift, after positioning him/her in the mechanical lift sling required for use with a mechanical lift, as the CNA's raised him/her up, one of the straps (looped end of… […]

• No harm, potential for more than minimal, patternF842Jan 8, 2026

  Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for two Residents (#6 and #10) out of 26 total sampled residents. Specifically:1.) For Resident #6, the nurse inaccurately documented a wound dressing change was completed multiple times when it was not.2.) For Resident #10, the nurses inaccurately documented a topical medication was applied multiple times when it was not.Findings include:Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. […]

• No harm, potential for more than minimal, isolatedF761Jan 8, 2026

  Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored in the original, labeled containers when two nurses stored multiple pre-poured medications in uncovered, unlabeled medication cups within the medication carts.Findings include:Review of the facility policy titled 'Medication Labeling and Storage', revised February 2023, indicated:-Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. […]

• No harm, potential for more than minimal, isolatedF607May 5, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 04/08/25, after Nurse #1 witnessed an incident of alleged physical abuse of the resident by staff member, Nurse #1 left Resident #1 and the accused staff member (Certified Nurse Aide (CNA) #1) alone together and did not immediately separate them. Findings include: Review of the Facility's Abuse Policy titled Recognizing Signs and Symptoms of Abuse, dated as revised April 2021, indicated all types of resident abuse are strictly prohibited and personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services… […]

• No harm, potential for more than minimal, isolatedF656Jan 23, 2025

  Based on record review and interviews, the facility failed to develop personalized care plans for two Residents (#87 and #92) out of a sample of 26 residents. Specifically: 1. For Resident #87, the facility failed to develop personalized care plans after the Speech Therapist made recommendations after two speech evaluations. 2. For Resident #92, the facility failed to develop a personalized history of substance abuse care plan. Findings include: A review of the facility policy titled, 'Care Plans, Comprehensive Person-Centered' with a revision date of December 2016 indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each… […]