Concord Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' personal and medical information was communicated in a way that protects personal privacy and confidential information for one sampled resident (Resident 1), when Resident 1's first name and medical information were communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many functions of a computer, typically having a touch screen and access). This failure resulted in violation of resident's right to secure and confidential personal and medical information. During a facility tour and concurrent interview on 7/8/26, at 10:20 a.m., with Infection Control Nurse (ICN), ICN stated he was using his smart phone to communicate with the housekeeping supervisor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by:1. The facility failed to ensure, for Residents 1-17, the scheduled (controlled medication, narcotic) medication system was complete (all documents readily available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out of four sampled residents (Resident 1), was protected from sexual abuse (non-consensual sexual contact of any type with a resident) when Certified Nurse Assistant (CNA) 1 was witnessed with his face on Resident 1's exposed right breast. This failure resulted in Resident 1 experiencing sexual abuse. This failure had the potential to cause emotional distress, feelings of shame, embarrassment, and an unsafe living environment due to Resident 1 experiencing sexual abuse from CNA 1.

Inspectors wroteBased on observation, interview and record review the facility failed to protect four of six sampled residents (Resident 2, Resident 3, Resident 4, and Resident 5) from physical abuse when following was noted:1. Resident 2 and Resident 3 got into a physical altercation with each other resulting in Resident 2 sustaining a one-inch scratch (shallow cut in the skin caused by trauma), to the left neck; and Resident 3 sustaining redness to the right forehead.2. Resident 4 and Resident 5 got into a physical altercation with each other resulting in Resident 4 sustaining a skin tear, (traumatic wound occurring when the top layer of skin separates from the underlying layer), to the front of the left arm, top of head, hand and forearm and a scratch to the right cheek and Resident 5 sustaining a scratch to the left upper lip. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to implement a comprehensive care plan for one of five sampled residents (Resident 1). The facility did not provide supervision to Resident 1 when she was in facility's patio. This failure resulted in Resident 1 falling on the ground sustaining a cut and bump to the back of the head and transfer to the acute care hospital for further care and evaluation. During a review of Resident 1's admission Record printed on 1/28/26, the record indicated Resident 1 was admitted to the facility in January 2017. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to one of three sampled residents (Resident 1), when Resident 1 with a history of wandering (traveling aimlessly form place to place), sustained an unwitnessed fall while ambulating on her own in the facility's patio area. This failure resulted in Resident 1 falling on the ground, sustaining a cut and bump to the back of the head, transfer to the acute care hospital for further care and evaluation. During a review of Resident 1's admission Record printed on 1/28/26, the record indicated Resident 1 was admitted to the facility in January 2017. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure compliance with required employment and licensure verification procedures when a previous staff member, who falsely represented themselves as a Registered Nurse (RN), used another person's RN license, and had a revoked Licensed Vocational Nurse (LVN) license in 2020 was hired and employed by the facility. These failures had the potential to place residents at risk for harm including medication errors, delays in necessary nursing interventions, and improper clinical decision-making by unlicensed nursing personnel. During a record review of Unlicensed Nurse (UN) 1's employee file, a printed copy of the RN nursing license dated 8/28/23, reflected a missing middle name and different spelling of the first name than that of UN 1. [...]

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours that involved 1 (Resident #18) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #108) of 35 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I preadmission screening and resident review (PASARR) was timely resubmitted after a resident remained in the facility longer than 30 days for 1 (Resident #145) of 4 sampled residents reviewed for PASARR.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a person-centered care plan to address the use of antidepressant medication, antipsychotic medication, and address a diagnosis of post-traumatic stress disorder (PTSD) for 1 (Resident #162) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on facility policy review, record reviews, interviews, and facility document review, the facility failed to ensure a resident's wheelchair was operable for 1 (Resident #7) of 1 sampled resident reviewed for accommodation of needs.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement their abuse prohibition policy when staff failed to identify an allegation as abuse. This failure to identify an allegation of abuse resulted in the allegation not being reported to the state, investigated, and the accused staff not being removed from resident contact, as directed by the facility's abuse prohibition policy for 1 (Resident #327) of 2 sampled residents reviewed for abuse.

Inspectors wroteBased on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 2 (Resident #142 and Resident #113) of 7 sampled residents reviewed for resident assessments.

Inspectors wroteBased on record reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #98, #85, and #110) of 7 sampled residents reviewed for resident assessments.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was accurate for 1 (Resident #176) of 3 sampled residents reviewed for closed record review.

Inspectors wroteBased on record reviews, interviews, and policy review, the facility failed to refer a resident with a newly evident serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 2 (Resident #48 and Resident #130) of 5 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure staff followed professional standards of practice by not leaving medications at the bedside of 1 (Resident #128) of 8 residents observed for medication administration.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was sanitized and properly stored for 1 (Resident #134) of 4 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure bed rails were used properly per assessment for 1 (Resident #152) of 5 sampled residents reviewed for accidents.

Inspectors wroteBased on the interviews, record review, document reviews, and policy review, the facility failed to act on a pharmacy recommendation to lower the dosage of medication for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review.

Inspectors wroteBased on observations, record reviews, interviews, document review, and policy review, the facility failed to have a medication error rate less than 5%. Specifically, there were two medication errors out of 25 opportunities, which yielded a medication error rate of 8% for 2 (Resident #89 and Resident #380) of 8 residents observed for medication administration.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure a resident's urinary catheter drainage bag was not on the floor for 1 (Resident #7) of 3 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received a written notification prior to being moved to another room within the facility. This failure placed Resident 1 at risk to experience increased anxiety and confusion related to spontaneous/unplanned change of environment.

Inspectors wroteBased on an interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment of necessity for special services relating to psychiatric and/or intellectual disability) assessment for one of three sampled residents (Resident 1) was completed accurately. Resident 1's PASARR assessment did not reflect current diagnoses of Anxiety (a feeling of fear, dread, and uneasiness). This failure placed Resident 1 at risk to not receive care and services appropriate to her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received incontinent care in a timely manner, when Resident 1 was left unchanged in a soiled incontinent disposable brief. This failure resulted in Resident 1 wearing a soiled/wet incontinent brief for an extended period of time and made him feel highly annoyed .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a secure location for one (1) of three (3) sampled residents (Resident 1), when Resident 1's medication was located unattended at the counter next to the sink near the door of Resident 1's room. This deficient practice had the potential for other residents, unauthorized staff, and visitors to have access to medications and the potential for misuse and ineffective treatment.

Inspectors wrote2. During a review of Resident 31's Minimal Data Set (MDS- An assessment used to plan care) assessment dated [DATE] indicated Resident 31 required extensive assistance with mobility. During an observation, on 5/5/21, at 9:10 a.m., in Resident 31's room, Resident 31's call light was clipped to the bed sheet at the head of the bed while Resident 31 was sitting in a wheelchair beyond the foot of the bed. During an interview, on 5/5/21, at 9:14 a.m., with Certified Nursing Assistant (CNA 11), CNA 11 stated the call light should be within Resident 31's reach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (Resident 599 and 140) of 21 sampled residents were provided a clean, safe and homelike environment when: 1. Resident 599 was missing a light fixture at the head of bed. This failure to provide a light fixture placed Resident 599 at risk for injury and the inability to perform his usual activities. 2. The bathroom in Resident 140's room had brown, dried fecal matter sticking on the toilet bowl and the floor. This failure provided an unclean and unsanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure 38 residents (Resident 20, 26, 2, 30, 25, 6, 7, 69, 38, 1, 19, 5, 90, 23, 39, 85, 8, 11, 18, 16, 13, 12, 89, 57, 125, 21, 92, 141, 60, 83, 43, 28, 97, 52, 14, 129, 53, and 98) of 45 sampled residents were assessed comprehensively, when the facility did not complete their Quarterly Minimal Data Set (MDS- An assessment used to plan care for residents) assessments for a period of seven months. This failure had the potential for residents to not receive individualized care based on their physical, mental and emotional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming assistance for four (Residents 106, 549, 140 and 497) of 32 sampled residents when: 1. Resident 106 was unshaved. 2 Resident 497 had long, fingernails with black dried substance underneath them. 3. Residents 549 had long fingernails with dark brown substance underneath them. 4. Resident 140 had long finger and toe nails with black substance underneath them. These failures to provide personal hygiene care to Residents 106, 549, 140, and 497 resulted in potential of low self esteem and self worth.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure Resident 249 was supervised by staff and the environment free from hazards. For Resident 249, this failure resulted in Resident 249 wandering, unnoticed by staff, in and out of residents' rooms, touching items that placed her at risk for injury and spread infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was prepared, stored, and served under sanitary condition when multiple plastic containers of salad dressing beyond the consumption date was found in the walk-in refrigerator This failure had the potential of putting residents at risk for food contamination and food-borne illness.

Inspectors wrote5. During an observation on, 5/5/21, at 9:19 a.m., in Resident 31's room, an incentive spirometer (a device with a mouthpiece and it helps the lungs to breathe deeply) was on Resident 31's bedside table. The incentive spirometer was left uncovered and its mouthpiece was touching the bedside table. During a concurrent observation and interview on, 5/5/21, at 9:25 a.m.,with Licensed Vocational Nurse (LVN 7), LVN 7 stated that the incentive spirometer should be kept in a plastic bag for infection control. LVN 7 further stated that if the spirometer was not covered, it could have bacteria grow and Resident 31 could breathe it in because that goes in her mouth. During a review of Resident 31's Physician Order Summary Report dated 5/6/21, the report showed an order for Incentive Spirometer for at least 15 minutes every shift for (Pneumonia- A lung disease) PNA prevention for Resident 31. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed toensure pateint care equipments were in safe operating conditions for two residents ( Resident 463 and 464) 0 f 32 sampled residents when:. 1. Resident 463's head of the bed cannot be elevated. 2. Resident 464 did not receive bedside rails to assist her with bed mobility and positioning. These failures resulted in the residents inabilities to achieve their highest practicable physical, mental and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Residents 60) of 32 sampled residents were treated with respect and dignity when the staff failed to close the privacy curtain during Resident 60's treatment procedure. This failure had the potential for unnecessary body exposure and embarrassment.

Inspectors wroteBased on observation, record review and interview, the facility failed to inform the physician of one of 32 sampled residents (Resident 31) worsening condition when Resident 31's physician was not informed of This failure had the potential to delay interventions and could lead to development of a wound infection.

Inspectors wroteBased on observation, interview and record review the facility failed to provide daily wound care treatment to Resident 499 per physician orders. This failure had the potential to result in worsening wounds, increasing the risk for localized and/or systemic infection for Resident 499.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent. There were two medication errors out of 29 opportunities, resulting in a 6.9 percent (%) medication error rate, when: 1. Licensed Vocational Nurse 1 (LVN 1) dispensed medication to Resident 45 from a medication container intended for Resident 498 ; and 2. LVN 1 dispensed high blood pressure medication to Resident 45 that should have been held per the physician's instructions on the prescription label. These deficient practices did not comply with safe medication administration practices and had the potential to cause harm and jeopardize Resident 45's physical health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 32 sampled residents (resident 140) was free from significant medication error when Furosemide (commonly known as Lasix and water pill) was not administered as ordered by the physician. This failure resulted in Resident 140's edematous (swollen) lower leg to worsen.