Concord Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that a resident's right to a safe, clean, comfortable, and homelike environment was maintained. This was evident on all resident units (Unit 2, 3 and 4). Specifically, rooms were not cleaned, hallways and day rooms were observed discolored with dark-brown color stains, days rooms and hallways were observed with cracked floor tiles, and days rooms also were observed with greasy dark stains in the corners.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report dated [NAME] 1st, 2025 to September 30th, 2025, was evident for low weekend staffing.

Inspectors wroteBased on observations, record review and staff interview, the facility failed to ensure that food was stored, prepared, and distributed, and that expired food in the walk-in freezer/refrigerator and the unit pantry were discarded in accordance with professional standards for food service safety. This was evident during the kitchen and unit pantry observation tasks. Specifically, food items were observed in the refrigerators with green, grey, black, and white fuzzy substances on them and expired food items were observed in the unit pantry resident refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure building elevators were maintained in safe working conditions. This was evident for (2) of three (3) elevators (Elevator #2 and #3) observed. Specifically, Elevators #2 and #3 were observed broken and was reported to be out of services for over several months, causing delays and restricting residents' movement around the facility, including delay of food services to the units.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident was free from physical restraints for purposes of discipline or convenience that are not required to treat the resident's medical symptoms, and did not ensure the evaluation of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This was evident for one (1) of three (3) residents investigated for Restraints out of 27 total sampled residents. Specifically, Resident #117 was observed wearing a hand mitten restraint on multiple occasions without a physician's order, resident or representative consent, or documentation reflecting ongoing re-evaluation for the need of the hand mitten restraint.

Inspectors wroteBased on record review and interviews, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs was completed and implemented for each resident. This was evident in 1 of 3 residents reviewed for Restraints out of 27 total sampled residents. Specifically, Resident #102 was observed to utilize a Wander Guard elopement prevention device without a corresponding Comprehensive Care Plan in place.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that the resident Comprehensive Care Plan was reviewed and revised for one (1) (Resident #6) of eight (8) residents reviewed for Accidents out of 27 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plan for Falls was reviewed and revised after the last quarterly Minimum Data Set assessment was completed and after the resident had a fall with injury.

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice. This was evident for 1 (Resident #23) out of 8 residents reviewed for Respiratory Care out of 27 sampled residents. Specifically, Resident #23 was observed using oxygen via undated nasal cannula at a rate of 4 liters per minute when the Physician's Order was written for oxygen to be received at a rate of 2 liters per minute.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments consistent with state or federal requirements and professional standards of practice. This was evident for 1 (4th Floor) of 4 units. Specifically, a large bag containing discontinued medications with multiple blister packs was observed on top of a desk at the 4th floor nurses' station. Additionally, stock medications were stored on the 4th floor nurses' station cabinet and were not locked.

Inspectors wroteBased on the observations and interviews, the facility did not ensure garbage was disposed of and refused properly. Specifically, waste, debris, and trash were not properly contained in closed dumpsters, and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests. This was observed during the Kitchen facility task.

Inspectors wroteBased on record reviews and interviews, the facility did not ensure that a comprehensive assessment of a resident was conducted in accordance with the required timeframes. This was evident for 15 (Resident #s 94, 17, 11, 41, 64, 140, 13, 17, 26, 37, 92, 46, 122, 103, 75) of 16 residents reviewed during the Resident Assessment Facility Task. Specifically, the admission and Annual assessments were not completed within 14 days of the Assessment Reference Date.

Inspectors wroteBased on record reviews and interviews, the facility did not ensure timely completion of each resident's quarterly review assessments. This was evident for 16 (Residents 140, 143, 64, 13, 17, 26, 37,46, 94, 41, 92,122,11,103, 93, and 75) of 16 residents reviewed during the Resident Assessment Facility Task. Specifically, the residents' Quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date.

Inspectors wroteBased on record review and interviews, the facility did not ensure Minimum Data Set Assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 16 (Residents #s 92, 37, 93, 17, 143, 13, 94, 26, 46, 64, 122, 11, 103, 75, 140, and 41) out of 16 residents reviewed for Resident Assessment Facility Task Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (652565), the facility failed to ensure that a resident, identified as an elopement risk, received adequate supervision to prevent elopement from the facility. This was evident for one (1) of five (5) residents (Resident #2) sampled. Specifically, on 11/29/2024 at 12:24 AM, Resident #2, who had severely impaired cognition, identified at risk for elopement, and was wearing a wander alert device, exited the facility building undetected by staff. Facility staff became aware Resident #2 was not in the building when Police Officers return the resident to the facility at 12:40 AM on 11/29/2024. Facility staff did not respond appropriately to an activated door alarm on Resident #2's unit.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) A resident's urinary drainage bag was observed on the floor on multiple occasions. This was evident for 1 (Resident #27) of 2 residents reviewed for Urinary Catheter out of 29 sampled residents. 2.) Registered Nurse #2 did not perform hand hygiene between glove changes during gastrostomy dressing change. This was evident for 1 (Resident #80) of 4 residents observed for the nutrition investigation. [...]

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure that residents remained free from physical restraint. This was evident in 1 (Resident #106) of 1 resident reviewed for Restraints out of 29 total sampled residents. Specifically, Resident #106 was observed with a mitten on the right hand. There was no documented evidence of appropriate assessment and care planning prior to the application of right hand mitten. Additionally, there was no documented monitoring provided while the right hand mitten was applied.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This was evident in 1 (4th floor) of 3 units. Specifically, on 07/24/2024 at 10:57 AM, Resident #14's medication were left unattended on top of the medication cart.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure that notice of the availability of the survey results was posted in areas of the facility that are prominent and accessible to the public. Specifically, the notice in the lobby of where to locate the survey results was posted in an area that was not accessible to the public; and there were no posted notices in resident units advising the residents, family members, or legal representatives of the survey results location.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure care plans were reviewed and revised by the interdisciplinary team. This was evident for 1 out of 4 residents (Resident #1) sampled. Specifically, Resident #1's toes, on their left lower extremity, was observed with discolorations on 06/21/2024. The Medical Doctor was notified and ordered an Arterial Doppler Study on 06/21/2024. Review of Resident #1's Comprehensive Care Plans, revealed that the risk for Impaired Skin Integrity care plan was not updated to reflect on the discolorations to Resident #1's left toes.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure that a resident medical record accurately reflected on the resident current condition. This was evident in 1 out 4 residents (Resident #1) sampled. Specifically, Resident #1's representative reported on 06/22/2024 at 5:00 pm that Resident #1's toes on the left lower extremity had discolorations. According to an interview with Primary Medical Doctor #1 on 07/10/2024 at 12:10 pm, they were in the facility and was notified of the discolorations on 06/21/2024. Primary Medical Doctor #1 stated that they assessed Resident #1 but did not document their assessment in Resident #1's medical record on 06/21/2024.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised after each assessment, including both the compehensive and quarterly reviewed assessments. This was evident for 1 (Resident #87) of 3 residents reviewed for pressure ulcers (PU). Specifically, the CCPs related to Resident #87's PUs were not reviewed and revised after each assessment to reflect changes in the condition of the wounds.

Inspectors wroteBased on observation, interviews, and record review during the recertification survey from 6/1/22 to 6/8/22, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #41) of 3 residents reviewed for limited range of motion. Specifically, Resident #41, a resident with bilateral hand contractures, was observed on multiple occasions without gauze rolls to bilateral hands as per Medical Doctor Order (MDO).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 6/1/22 to 6/8/22, the facility did not ensure a resident's medical records were complete. This was evidenced by 1 (Resident #72) of 5 residents reviewed for unnecessary medication. Specifically, there was no documented evidence in the Medication Administration Record (MAR) Resident #72 received their hypertensive medication as per Medical Doctor Order (MDO) on multiple occasions.