Concordia at Rebecca Residence

Inspectors wroteBased on a review of facility policies, facility forms, observations and staff interviews it was determined that the facility failed to properly date, and store food products, and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Monitoring of Cooler/Freezer Temperature last reviewed 11/1/25, indicated that all food items will be stored at least 6 inches off the ground and 18 inches from the ceiling. Refrigerated food shall be labeled dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable. Review of the facility policy Dishwasher Temperature Procedure, last reviewed 11/1/25, indicated that all items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. [...]

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of four residents sampled with facility-initiated transfers (Residents R1, R2, R65, and R82), and failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for two of two resident (Residents R4, and R84).

Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for two of four residents (Resident R1, and R65).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for two of eight residents (Resident R52 and R67).

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for three of ten residents (Resident R1, R49, and R65).

Inspectors wroteBased on review of facility policies, clinical records and staff interview, it was determined that the facility failed to individualize care plans to address the resident specific nutrition, and hydration concerns for two of two residents (Resident R27, and R49).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (First Floor), failed to ensure medication supplements were administered correctly for one of four residents (Resident R17), and failed to secure a medication cart for one of four medication carts (First Floor).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two crash carts (a cart that contains supplies in the event of an emergency), (First Floor) and one of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (First Floor).

Inspectors wroteBased on review of facility policy, facility documentation and staff interview, it was determined that the facility failed to have documentation of grievances for 2026.

Inspectors wroteBased on a review of facility documentation, and staff interviews it was determined that the facility failed to ensure a licensed nurse is designated to serve as a charge nurse on each tour of duty, except when waived for 21 of 21 days (11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen equipment and CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a bi-level positive airway pressure machine when breathing in and breathing out) management for four of six residents (Residents R10, R154, R155, and R156).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for three of twelve resident rooms (Residents R6, R19, and R159).

Inspectors wroteBased on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan, that included the minimum healthcare information necessary to properly care for a resident was fully developed and implemented for two of seven residents (Residents R154 and R155).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update care plans to be reflective of residents' current needs for two of seven residents (Residents R10 and R33).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the dish in the main kitchen which created the potential for cross contamination.

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for weights four out of six residents (Resident R10, R26, R29, and R207).

Inspectors wroteBased on review of facility policy, resident grievances, resident, resident family member, and staff interviews, it was determined that the facility failed to record the nature and specifics of verbalized grievances related to resident clinical care concerns on the designated grievance form as required for one of three residents (Resident R29).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents with facility-initiated transfer (Residents R7 and R10).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of four residents (Residents R7 and R10).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of four residents (Residents R7 and R10).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of seven residents (Resident R45).

Inspectors wroteBased on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of residents (Resident R35 & R37).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to obtain a physician order for type and care of a supra-pubic catheter (a hollow flexible tube that is used to drain urine from the bladder that is inserted into the bladder through a cut in the abdomen) for one of three residents (Resident R207).

Inspectors wroteBased a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that nutritional supplement intakes were documented accurately for two of five residents (Resident R18 and R26), failed to develop an individualized care plan to address the residents' specific nutritional interventions for one of five residents (Resident R18), and failed to complete a comprehensive nutritional assessment due to status change for one of five residents (Resident R26).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a wound dressing change for one of three residents (Resident R42) and failed to maintain designated dressing change intervals for one of three residents with a (PICC) peripherally inserted central catheter (Resident R17).

Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurse reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance.

Inspectors wroteBased on review of policies and information provided by the facility, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out that abuse was involved for one of 43 residents reviewed (Resident 43). This deficiency was cited as past non-compliance.