Concordia at Arbutus Park

In the surveyor’s words

From the most serious findings on record at Concordia at Arbutus Park, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 14, 2024

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for preventing falls for one of four residents reviewed (Resident 1), resulting in a fall and fracture for the resident. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated January 10, 2024, revealed that neglect is defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF656Mar 14, 2024

  Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of four residents reviewed (Resident 1) that was identified as a fall risk, resulting in a fall and fracture for the resident. This deficiency was cited as past noncompliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 5, 2024, revealed that the resident was cognitively intact and had diagnoses of seizure disorder. […]

• Actual harm, isolatedF689Mar 14, 2024

  Based on review of the facility's policies, investigation documents, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of four residents reviewed (Resident 1) resulting in a fall with fracture. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding gait belts (used to help nursing staff support a person who is unsteady or weak) for transfers and ambulation (walking), dated January 10, 2024, revealed that gait belts are provided to assist staff to safely transfer or ambulate residents. […]

• Actual harm, isolatedF600Jul 12, 2022

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and the facility's policy for preventing falls for one of five residents reviewed (Resident 1), resulting in a fracture for the resident. Findings include: The facility's policy regarding fall prevention and protocol, dated December 14, 2021, indicated that staff members will be written up as a negative performance notation for failing to use the recommended interventions or failing to put a resident alarm in the on position. […]

• No harm, potential for more than minimal, patternF689Apr 9, 2025

  Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of four residents reviewed (Resident 1). This deficiency was cited as Past Non-Compliance. Findings include: The facility's policy regarding residents who wander, dated January 16, 2025, indicated that the residents in the facility will be provided with a safe environment in which to live. […]