Concord Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF600May 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure for one out of four sampled residents (Resident 1), was protected from sexual abuse (non-consensual sexual contact of any type with a resident) when Certified Nurse Assistant (CNA) 1 was witnessed with his face on Resident 1's exposed right breast.This failure resulted in Resident 1 experiencing sexual abuse.This failure had the potential to cause emotional distress, feelings of shame, embarrassment, and an unsafe living environment due to Resident 1 experiencing sexual abuse from CNA 1.Findings:During a record review of the facility's Report of Suspected Dependent Adult/Elder Abuse form SOC 341 sent to the State Agency, the form indicated that on 4/30/26 at 3:14 p.m., CNA 1 was reported to have sexually… […]

• No harm, potential for more than minimal, widespreadF755Jul 8, 2026

  Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by:1. The facility failed to ensure, for Residents 1-17, the scheduled (controlled medication, narcotic) medication system was complete (all documents readily available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. […]

• No harm, potential for more than minimal, patternF600Feb 5, 2026

  Based on observation, interview and record review the facility failed to protect four of six sampled residents (Resident 2, Resident 3, Resident 4, and Resident 5) from physical abuse when following was noted:1. Resident 2 and Resident 3 got into a physical altercation with each other resulting in Resident 2 sustaining a one-inch scratch (shallow cut in the skin caused by trauma), to the left neck; and Resident 3 sustaining redness to the right forehead.2. Resident 4 and Resident 5 got into a physical altercation with each other resulting in Resident 4 sustaining a skin tear, (traumatic wound occurring when the top layer of skin separates from the underlying layer), to the front of the left arm, top of head, hand and forearm and a scratch to the right cheek and Resident 5 sustaining a… […]

• No harm, potential for more than minimal, patternF558May 7, 2021

  Based on observation, interview and record review, the facility failed to ensure needs were not accommodated timely for two (Resident 460 and Resident 31) of 32 sampled resident when Resident 460 and 31's call light was positioned out of reach. These failures had the potential to result in Resident 460 and 31 not being able to alert staff in case of an emergency or needs. Findings: 1. During an observation and interview with Resident 460 on 5/3/2021, at 9:05 a.m., Resident 460 stated she had been pressing her call light button for the past hour and a half and no one had responded. Resident 460 was holding the bed control device with her right hand. Resident 460 stated the CNA gave her this button to press when she needed assistance. […]

• No harm, potential for more than minimal, patternF584May 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure two (Resident 599 and 140) of 21 sampled residents were provided a clean, safe and homelike environment when: 1. Resident 599 was missing a light fixture at the head of bed. This failure to provide a light fixture placed Resident 599 at risk for injury and the inability to perform his usual activities. 2. The bathroom in Resident 140's room had brown, dried fecal matter sticking on the toilet bowl and the floor. This failure provided an unclean and unsanitary environment. Findings: 1. During an observation on 5/3/21, at 11:21 a.m., Resident 599 was lying in bed, with his privacy curtains closed. […]