The Health Center at Concordia

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Nov 19, 2024

  Based on observation and interview, the facility failed to ensure food was being prepared in accordance with professional standards of practice for food safety. The DON identified 27 residents resided in the facility. Findings: On 11/13/24 at 9:57 a.m., Dietary Aide #1 was observed preparing and rinsing fresh food items in the left compartment of the sink. In the right compartment of the sink raw fish was being defrosted with running water. On 11/13/24 at 9:58 a.m. the dietary manager reported the dietary aide #1 was not to rinse and prepare fresh food items in the sink compartment next to the raw fish defrosting.

• No harm, potential for more than minimal, patternF578Nov 19, 2024

  Based on record review and interview, the facility failed to ensure an advance directive was available for one (#2) of two sampled residents reviewed for advance directives. The DON identified 27 residents resided in the facility. Findings: An Advance Directive policy, dated 11/01/07, read in part, 9. If the resident has prepared such documents, obtain a copy and place in the resident's clinical record. Res #2's clinical record was reviewed. There was no advance directive available. On 11/14/24 at 2:58 p.m., the social services director reported there was no documentation of Res #2's advance directive.

• No harm, potential for more than minimal, patternF880Nov 19, 2024

  Based on observation, interview, and record review, the facility staff failed to implement infection control measures when using the blood pressure cuffs from resident to resident. The DON identified 24 residents depended on staff to obtain their blood pressure before administering medication. Findings: The infection control policy, dated 09/23/23, documented the purpose was to provide and ensure an ongoing program to establish and maintain an infection prevention and control program to provide safety, sanitary, and comfortable environment and prevent the development and transmission of communicable disease and infections. […]

• No harm, potential for more than minimal, patternF880Sep 13, 2023

  Based on record review and interview, the facility failed to ensure: a. infection control tracking and trending was conducted for three (June, July, and August) of six months reviewed for infection control, and b. a water management system was in place to detect/prevent Legionella. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 28 residents resided in the facility. Findings: 1. Infection control logs were reviewed for the past six months. There was no documentation infection control tracking and trending had been conducted in June, July, or August 2023. On 09/12/23 at 11:28 a.m., the Administrator was asked what the policy was for infection control tracking and trending 2023 tracking and trending. She stated they could not locate it. […]

• No harm, potential for more than minimal, patternF880Aug 25, 2022

  Based on record review and interview, the facility failed to ensure tracking and trending of infections had been conducted for four months (December '21, April '22, May '22, and June '22) of the last twelve months reviewed for infection control. The Resident Census and Conditions of Residents report, dated 08/25/22, documented 27 residents resided in the facility. Findings: An Infection Control Surveillance policy, dated 2007, read in part, .PURPOSE .To conduct surveillance of resident and employee infections to guide prevention activities . Infection control tracking and trending was reviewed from September 2021 through July 2022. […]