Concordia Nursing & Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Concordia Nursing & Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF727May 6, 2025

  Based on observations, interviews, record review, facility document review, facility policy review, the facility failed to ensure employment of a full-time Director of Nursing to manage the nursing department and provide oversight of care and planning to all residents; and to ensure a registered nurse was available in the building for 8 consecutive hours a day for resident needs. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, widespreadF835May 6, 2025

  Based on interview, record review and policy review the administration (governing body) failed to ensure policies were implemented regarding management and operation of the facility to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During the survey, the survey team identified no full-time registered nurse (RN) working 8 consecutive hours per day and licensed practical nurses (LPN) were not certified to assess and manage peripherally insert center catheters (PICC). Additionally, the survey team identified bed rails were installed without consent and residents were not assessed for their needs. The survey team identified residents with falls had not received fall assessments and interventions to prevent further falls. […]

• Immediate jeopardy, patternF689May 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 25) of 2 residents reviewed for falls/accidents received proper assessments and interventions to prevent falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 25 incidents/accident reports, care plans and closet care plans. […]

• Immediate jeopardy, patternF700May 6, 2025

  Based on interviews, record review, and facility document review, the facility failed to ensure bed rail assessments were completed for resident needs and safety, to obtain informed consent prior to installation of bed rails, and to ensure identified bed rails were applied to a compatible bed based on the assessed resident needs. Bed rails found installed on resident beds for 2 residents (Resident #15 and #25) that were reviewed for bed rails. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, patternF726May 6, 2025

  Based on interviews, record review, facility document review, facility policy review, the facility failed to ensure a nurse with the training and competencies were on staff to provide the ordered necessary care to the residents. Specifically, the facility did not ensure Licensed Practical Nurses (LPNs) with Intravenous (IV) certification accessed and managed Resident #33's Peripherally Inserted Center Catheter (PICC) line including IV antibiotic administration, IV flushes, and assessment of the line's condition and status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]