Concordia Manor

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect the residents' right to be free from neglect related to ensuring safety during bed mobility consistent with the assessed and care planned needs for three residents (#2, #5, and #6) of three residents sampled for abuse and neglect. Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. Resident #2, a vulnerable resident, was not promptly assessed post fall, and the resident's acute pain was not addressed in a timely manner. The facility failed to ensure Resident #2 was seen by a physician and that an ordered X-ray was completed. Resident #2, who was contracted and had other comorbidities, was not a candidate for surgical intervention resulting in on-going physical and psychosocial pain. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the number of staff needed to ensure safety during bed mobility consistent with the assessed and care planned needs for four residents (#2, #3, #5 and #6) of five residents sampled for falls. Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. Resident #2, a vulnerable resident, was not promptly assessed post fall, and the resident's acute pain was not addressed in a timely manner. The facility failed to ensure Resident #2 was seen by a physician and that an ordered X-ray was completed. Resident #2, who was contracted and had other comorbidities, was not a candidate for surgical intervention resulting in on-going physical and psychosocial pain. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure pain control and management for residents' post fall for two residents (#2 and #5) of three residents reviewed. Resident #2 sustained a femur fracture which she was not a surgical candidate for. Resident #2 continued to have uncontrolled pain which continued to affect her activities of daily living. The facility failed to accurately assess and notify the physician of Resident #2's uncontrolled pain. Resulting in on-going physical pain and psychosocial harm. Resident #2 sustained a fall from the bed during care, resulting in a transfer to a higher level of care due to acute pain and was diagnosed with a hip fracture. Resident #2, a vulnerable resident, was not promptly assessed post fall, and the resident's acute pain was not addressed in a timely manner. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to honor a resident's shower preferences for one resident (#4) of one sampled.

Inspectors wroteBased on observation, interview, and record review, the facility neglected to provide the number of staff needed to ensure safety during bed mobility consistent with the assessed and care planned needs for one (#1) of two residents sampled for abuse and neglect. Resident #1 sustained a fall from the bed resulting in a transfer to a higher level of care, and head injury.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of abuse in a timely manner for two (#1 and #3) of two residents sampled for abuse and neglect. (Cross reference F600 and F610)

Inspectors wroteBased on interviews and record review, the facility failed to investigate thoroughly and timely allegations of abuse for two (#1 and #3) of two residents sampled for abuse and neglect. (Cross reference F600 and F609)

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one (#1) of two residents sampled.

Inspectors wroteBased on observation record review and interviews, the facility failed to ensure timely incontinence care and services were provided to promote Quality of Life for one (#2) of five sampled residents.

Inspectors wroteBased on observation record review and interviews, the facility failed to ensure timely repairs were completed for one of three air conditioning units and failed to ensure resident rooms were maintained in a safe and sanitary manner in two resident rooms (104 and 105) related to cracking, peeling, and dislodged ceiling material with discoloration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in six (105, 106, 109, 110, 111, and 112) out of eleven resident rooms and the medication room. Findings Included: During a facility tour on 5/7/24 at 9:30 a.m. the following observations were made: In room [ROOM NUMBER] there was a hole in the wall next to the resident's bed. Around the bed the wire mold was split and there were exposed wires. The base board next to the sink was separating from the wall. (Photographic Evidence Obtained). In room [ROOM NUMBER] there was a deep hole in the wall where the concrete infrastructure was observed next to the resident's bed. (Photographic Evidence Obtained). On 5/7/2024 at 9:40 a.m. during a tour of common areas and resident rooms, the following observations were made in resident rooms 109, 110, 111 and 112. [...]

Inspectors wroteBased on observation, record review, interview and review of the facility's policy Policy and Procedure: Topic Safety the facility failed to ensure kitchen equipment was being utilized in safe operating conditions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident and resident representative received a bed hold notification prior to and upon transfer to the hospital for one (Resident #29) of two residents reviewed for bed hold notification.

Inspectors wroteBased on record review, interview and review of the facility's policy PASRR Requirements Level I & Level II, the facility failed to ensure seven (Residents #3, #5, #13, #18, #19, #20 and #26) of fourteen sample residents reviewed for PASRR screens had an accurate Level 1 Pre-admission Screening & Resident Review (PASRR).

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate resident preferences for activities based on assessments for two residents (#4, #13) of two residents sampled, related to not ensuring enough electrical outlets for an appliance (television) functionality.

Inspectors wroteBased on interview and record review the facility failed to administer blood pressure medications according to the physicians ordered blood pressure parameters for two residents (#2 and #33) of seven residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain a physician response and to implement orders related to pharmacy recommendations in a timely manner for one (#19) out of five residents sampled for unnecessary medications.