Concordia Manor

In the surveyor’s words

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

• Immediate jeopardy, patternF600Sep 10, 2025

  Based on observation, interviews, and record review, the facility failed to protect the residents' right to be free from neglect related to ensuring safety during bed mobility consistent with the assessed and care planned needs for three residents (#2, #5, and #6) of three residents sampled for abuse and neglect.Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. Resident #2, a vulnerable resident, was not promptly assessed post fall, and the resident's acute pain was not addressed in a timely manner. The facility failed to ensure Resident #2 was seen by a physician and that an ordered X-ray was completed. […]

• Immediate jeopardy, patternF689Sep 10, 2025

  Based on observation, interviews, and record review, the facility failed to provide the number of staff needed to ensure safety during bed mobility consistent with the assessed and care planned needs for four residents (#2, #3, #5 and #6) of five residents sampled for falls.Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. Resident #2, a vulnerable resident, was not promptly assessed post fall, and the resident's acute pain was not addressed in a timely manner. The facility failed to ensure Resident #2 was seen by a physician and that an ordered X-ray was completed. […]

• Immediate jeopardy, patternF697Sep 10, 2025

  Based on observation, interviews, and record review, the facility failed to ensure pain control and management for residents' post fall for two residents (#2 and #5) of three residents reviewed. Resident #2 sustained a femur fracture which she was not a surgical candidate for. Resident #2 continued to have uncontrolled pain which continued to affect her activities of daily living. The facility failed to accurately assess and notify the physician of Resident #2's uncontrolled pain. Resulting in on-going physical pain and psychosocial harm.Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. […]

• Actual harm, isolatedF600Apr 23, 2025

  Based on observation, interview, and record review, the facility neglected to provide the number of staff needed to ensure safety during bed mobility consistent with the assessed and care planned needs for one (#1) of two residents sampled for abuse and neglect. Resident #1 sustained a fall from the bed resulting in a transfer to a higher level of care, and head injury. Findings included: On [DATE] at 11:29 a.m., Resident #1 was observed laying in bed. The resident's right arm was resting on his chest and was contracted. Resident #1 was non-verbal but nodded yes or no to questions. He nodded yes to remembering a fall incident. He nodded yes to being in pain. He shrugged his shoulders when asked if he was injured. […]

• No harm, potential for more than minimal, patternF584May 9, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in six (105, 106, 109, 110, 111, and 112) out of eleven resident rooms and the medication room. Findings Included: During a facility tour on 5/7/24 at 9:30 a.m. the following observations were made: In room [ROOM NUMBER] there was a hole in the wall next to the resident's bed. Around the bed the wire mold was split and there were exposed wires. The base board next to the sink was separating from the wall. (Photographic Evidence Obtained). In room [ROOM NUMBER] there was a deep hole in the wall where the concrete infrastructure was observed next to the resident's bed. (Photographic Evidence Obtained). On 5/7/2024 at 9:40 a.m. […]