Concordia Village Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jun 26, 2024

  Based on interview and record review, the facility failed to provide timely assessment and treatment of humeral fracture in 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in a delay of care for R2's humeral fracture from, at a minimum, 5:30 PM on 6/12/24 to 12:34 PM on 6/13/24. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE], with diagnoses including dementia, depression, muscle weakness, osteoporosis, and history of falling. R2's, undated, Minimum Data Set/MDS documented R2 was severely cognitively impaired with inattention, disorganized thinking, and altered level of consciousness. […]

• Actual harm, isolatedF760Sep 21, 2023

  Based on interview and record review, the facility failed to ensure medications were given as prescribed, as well as at the time frame as ordered, for 2 of 5 residents, (R32, R104) reviewed for medications, in the sample of 28. This failure caused R32's medication to be omitted for 5 doses/nights, causing R32 to experience wandering behaviors requiring intervention. Findings include: 1. R32's Face Sheet, dated 9/20/2023, documents R32 has Alzheimer's Disease, Dementia with Behavioral Disturbances, Insomnia, and Hallucinations. R32's Administration Record documents, Trazodone 100 mg, (Milligrams), tablet one time daily starting 12/23/2022. Indication: Insomnia. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2024

  Based on interview, observation, and record review, the facility failed to label and date food products, restrain hair, and ensure resident use refrigerators are only used for residents to prevent foodborne illness. This failure has the potential to affect all 51 residents residing at the facility. Findings include: On 8/19/24 at 10:30 AM, the main kitchen was observed. The walk in refrigerator had a container of meat (which appeared to be tuna). The container was not labeled or dated. The main kitchen freezer had a metal sheet pan lying on the floor. There was a frozen bag with red pasta sauce on the sheet pan. At 10:40 AM, the Summer hall kitchen refrigerators were observed. […]

• No harm, potential for more than minimal, widespreadF761Sep 21, 2023

  Based on observation, interview, and record review, the facility failed to secure medications appropriately, and failed to label and date open bottles of medications. The facility also failed to ensure medications requiring refrigeration were monitored and documented per the Facility policy. This has the potential to affect all 49 residents living in the facility. Findings include: 1. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. […]

• No harm, potential for more than minimal, widespreadF761Oct 20, 2022

  Based on interview, observation, and record review, the facility failed to safely secure and store medications in a locked medication cart, failed to dispose of expired medications in the medication cart, and failed to properly label medications with a resident name and the open date. These failures have the potential to affect all 44 residents in the facility. Findings include: 1. On 10/17/22 at 11:20 AM, the medication cart located on the 6200 hall, (Reach), was seen unlocked with no nurse in sight. No residents were seen around the cart. V7, RN, (Registered Nurse), was working this hall and caring for residents. 2. […]