Concord Health & Rehab Ctr

Inspectors wroteBased on medical record review and staff interview, the facility failed to properly submit a discharge assessment following its completion. This affected one resident (#1) of three residents reviewed for discharge assessments. The facility census was 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a baseline plan of care for Resident #87 upon admission who was admitted with a gastrostomy tube. This affected one resident (#87) of 20 residents reviewed for care plans. The facility census was 74.

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure care planned fall prevention interventions were in place. This affected one resident (#12) of two residents reviewed for falls. The facility census was 74. Findings Include:Review of the medical record for Resident #12 revealed an admission date of 03/13/26 with a readmission date of 05/29/26. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, depression, generalized muscle weakness, abnormalities of gait and mobility, symbolic dysfunction, dysphagia, adult failure to thrive, protein calorie malnutrition, peripheral vascular disease, adjustment disorder with mixed anxiety and depressed mood, hypertension, insomnia, hypothyroidism, mixed anxiety disorders and chronic respiratory failure. [...]

Inspectors wroteBased on interview and record review, the facility failed to have parameters for administration of two as needed pain medications for Resident #33. This affected one resident of five reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #31 had appropriate clinical reason/diagnosis for the use of an antipsychotic medication. This affected one (#31) of five residents reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased on closed medical record review, staff interviews and facility policy review, the facility failed to ensure the Power of Attorney (POA) was notified of a change in condition in the area of skin tears for one resident (#74). This affected one (Resident #74) of three residents reviewed for notification. The facility census was 73. Findings Include: [...]

Inspectors wroteBased on closed medical record review, interviews, facility investigation review and facility policy review, the facility failed to report an allegation of abuse to the required state agency for one resident (#74). This affected one (Resident #74) of three residents reviewed for abuse. The facility census was 73. Findings Include: [...]

Inspectors wroteBased on closed medical record review, interviews, facility investigation review and facility policy review, the facility failed to complete a thorough investigation for an allegation of abuse for one resident (#74). This affected one (Resident #74) of three residents reviewed for abuse. The facility census was 73. Findings Include: [...]

Inspectors wroteBased on review of resident personal funds accounts, policy and procedure review and interview the facility failed to ensure residents who were within $200.00 of the Social Security Income (SSI) resource limit of $2,000.00 were assisted in spending down the money so the resident did not lose their Medicaid eligibility. This affected two residents (#32 and #60) of five residents reviewed for personal funds.

Inspectors wroteBased on review medical record review, policy and procedure review and interview the facility failed to ensure Resident #45's medical record contained evidence of contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and comprehensive care plan goals when the resident was discharged to the hospital. This affected one resident (#45) of one resident reviewed for hospitalization.

Inspectors wroteBased on medical record review, facility policy and procedure review and interview the facility failed to ensure bed hold information was provided to Resident #45 and/or the resident's representative at the time of transfer to the hospital. This affected one resident (#45) of one resident reviewed for hospitalization.

Inspectors wroteBased on medical record review, review of Centers for Medicare and Medicaid (CMS) guidance and interview the facility failed to timely complete and submit a Minimum Data Set (MDS) assessment for Resident #63, who had been discharged from the facility. This affected one resident (#63) of 20 residents whose MDS 3.0 assessments were reviewed.

Inspectors wroteBased on observation, medical record review, review of Centers for Medicare and Medicaid (CMS) guidance and interview the facility failed to ensure Resident #14's Minimum Data Set (MDS) 3.0 assessments were accurate to reflect the resident's limitations in functional mobility/range of motion. This affected one resident (#14) of 20 residents whose MDS 3.0 assessments were reviewed.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) assessment for Resident #23 was accurately completed upon admission to the facility. This affected one resident (#23) of three residents reviewed for timely and accurate PASARR assessments.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure comprehensive care plans were developed and implemented for Resident #14 and Resident #29 related to functional mobility/contractures. This affected two residents (#14 and #29) of three residents reviewed for range of motion.

Inspectors wroteBased on medical record review and interview the facility failed to ensure residents and/or their responsible party were invited and participated in quarterly care conferences/interdisciplinary team meetings. This affected two residents (#20 and #25) of three residents reviewed for care conferences.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement comprehensive and individualized range of motion treatment and services for Resident #29 to address contractures/limitations in range in motion to the resident's bilateral upper extremities/hands. This affected one resident (#29) of three residents reviewed for range of motion.

Inspectors wroteBased on medical record review and interview the facility failed to ensure appropriate diagnoses/justification for the use of psychoactive medications for Resident #16. This affected one resident (#16) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, facility policy and procedure review, Centers for Medicare and Medicaid (CMS) Quality Safety and Oversight (QSO) 22-09-ALL review and interview the facility failed to implemented their COVID-19 vaccination plan and failed to ensure 100 percent of staff were fully vaccinated against COVID-19, were temporarily delayed or had been granted a medical or religious exemption as required. This had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Medical Director (MD) and/or MD representative attended quarterly QAA meetings. This had the potential to affect all 60 residents residing in the facility.