Concordia Nursing & Rehab, LLC

Inspectors wroteBased on observations, interviews, record review, facility document review, facility policy review, the facility failed to ensure employment of a full-time Director of Nursing to manage the nursing department and provide oversight of care and planning to all residents; and to ensure a registered nurse was available in the building for 8 consecutive hours a day for resident needs. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of L. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; [...]

Inspectors wroteBased on interview, record review and policy review the administration (governing body) failed to ensure policies were implemented regarding management and operation of the facility to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During the survey, the survey team identified no full-time registered nurse (RN) working 8 consecutive hours per day and licensed practical nurses (LPN) were not certified to assess and manage peripherally insert center catheters (PICC). Additionally, the survey team identified bed rails were installed without consent and residents were not assessed for their needs. The survey team identified residents with falls had not received fall assessments and interventions to prevent further falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident 25) of 2 residents reviewed for falls/accidents received proper assessments and interventions to prevent falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 25 incidents/accident reports, care plans and closet care plans. The review revealed three interventions for nine documented falls for Resident 25. The Administrator was notified of the IJ on 04/29/2024 at 8:46 AM. A Removal Plan was requested. [...]

Inspectors wroteBased on interviews, record review, and facility document review, the facility failed to ensure bed rail assessments were completed for resident needs and safety, to obtain informed consent prior to installation of bed rails, and to ensure identified bed rails were applied to a compatible bed based on the assessed resident needs. Bed rails found installed on resident beds for 2 residents (Resident #15 and #25) that were reviewed for bed rails. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. [...]

Inspectors wroteBased on interviews, record review, facility document review, facility policy review, the facility failed to ensure a nurse with the training and competencies were on staff to provide the ordered necessary care to the residents. Specifically, the facility did not ensure Licensed Practical Nurses (LPNs) with Intravenous (IV) certification accessed and managed Resident #33's Peripherally Inserted Center Catheter (PICC) line including IV antibiotic administration, IV flushes, and assessment of the line's condition and status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of K. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #184) of 1 sampled resident did not have a decline in mobility functions with psychosocial harm after admission. Specifically, the facility failed to assess the resident's mobility function, identify interventions, and provide necessary equipment for Resident #184 to maintain their most practicable independence. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/02/25 after Resident #184's admission. [...]

Inspectors wroteBased on observations, interviews, and facility document reviews, it was determined that the facility failed to post the last survey results in an accessible location for the residents' review.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure Certified Nursing Assistants (CNAs) were certified as CNAs in the State of Arkansas, and failed to ensure background checks were completed for 2 Nurse Aides reviewed for qualified staffing.

Inspectors wroteBased on facility document review, and facility policy review, it was determined that the facility failed to conduct a thorough self-assessment for facility staffing available, the competencies and training of the staff, conduct community-based risk analysis identifying the potential natural disasters, and formulate a plan for staff recruitment to meet the needs of the residents when the facility assessment was received.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined that the facility failed to have an organized record management system, accurately documented and readily available to staff, nor completed medical records of the residents to ensure proper treatment, continuity of care and clarity for the facility's staff to safely care for the residents. Specifically, physician orders, comprehensive care plans, Minimum Data Sets (MDS), Medication Administration Record (MAR), and Treatment Administration Record (TAR).

Inspectors wroteBased on interviews, the facility failed to provide disclosure of ownership paperwork upon request. On 04/26/2025 at 10:44 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/28/2025 at 12:46 PM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, the Administrator reported that the Director of Operations was coming that day and information would be provided as requested. On 05/06/2025 at 11:47 AM, at time of survey exit, disclosure of ownership was never provided as requested.

Inspectors wroteBased on interviews and facility document reviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for all staff members in the facility upon hire, and provide in-services to direct staff when reviewed for required QAPI training.

Inspectors wroteBased on interviews and facility document reviews, it was determined that the facility failed to provide Compliance and Ethics training for all staff members in the facility upon hire, and provide in-services to direct staff, when reviewed for required compliance and ethics training.

Inspectors wroteBased on observations, interviews, record review, facility document review and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed in the required timeframe of 14 days for 4 (Resident #26, #85, #135, #184) of 4 residents reviewed for MDS assessment and timing.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Residents #25, #184) of 3 residents reviewed for MDS accuracy. Specifically, the facility failed to identify and ensure information regarding bedrails was accurately assessed and completed on the MDS for Resident #25; and to identify and ensure the Oxygen Nasal Cannula (NC) and Continuous Positive Airway Pressure (CPAP) were accurately assessed and completed on the MDS for Resident #184.

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for 4 (Residents #26, # 85, #135, and #184) of 4 residents reviewed for comprehensive care planning.

Inspectors wroteBased on observations, interviews, record review, and facility document review, the facility failed to review and revise the comprehensive person-centered care plan in the required timeframe for two (Residents #15, #25) of two sampled residents reviewed for comprehensive care plan completion. Specifically, Resident #15 did not have revisions and escalated interventions for repeated falls; Resident #25 did not have revisions and interventions after a fall with major injury.

Inspectors wroteBased on observation, facility policy review, and interviews, the facility failed to ensure that the kitchen's fryer was clean and free from food particles; food had not been kept past the expiration and storage date; food was labeled and dated; to separate resident's food from employee's food in unit refrigerator; and food was covered for one of one kitchen reviewed for food storage, preparation, and sanitation practices.

Inspectors wroteBased on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure the arbitration agreement, signed by residents or their representatives stated it was not a condition of admission.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined that the facility failed to ensure the arbitration agreement signed by residents or their representatives stated in case of an arbitration dispute meeting a venue which is convenient for both parties would be utilized.

Inspectors wroteBased on observations, interviews, facility policy review, and document review, it was determined that the facility failed to identify a resident, Resident #33, who required Transmission Based Precautions (TBP) for an infected wound; completed wound care without utilizing appropriate Personal Protective Equipment (PPE); and failed to identify a resident, Resident #135, who required Enhanced Barrier Precautions (EBP); failed to have Personal Protective Equipment (PPE) available; and failed to ensure staff maintained clean technique while performing urinary catheter care, to prevent the spread of infection and cross contamination. This failed practice had the potential to spread infection to two (Resident #33, #135) of two sampled residents observed for wound care and urinary catheter care.

Inspectors wroteBased on record review and interviews, the facility failed to implement a dietary recommendation for one (Resident #4) of one sampled resident reviewed for dietary recommendations.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to develop a baseline care plan for one (Resident #85) of one resident reviewed for baseline care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly notify the Medical Director and the Registered Dietitian of progressive weight loss in order to minimize further weight loss and to maintain nutritional status to the extent possible for 1 (Resident #21) of 3 sampled residents (Residents #9, #21, and #26) who had experienced weight loss. The failed practice resulted in a pattern of actual harm for Resident #21 who experienced a severe unplanned 24lb (24.8%) weight loss in 6 months and had the potential of cause more than minimal harm for 3 residents who had experienced weight loss in the past 6 months, according to list provided by the Director of Nursing on 1/31/24 at approximately 11:50 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff washed their hands with soap and water between dirty and clean tasks to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen, dishes were air dried, and foods were stored properly. The failed practice had the ability to affect all 28 residents who receive their meals from 1 of 1 kitchen according to a list provided by the administrator on 1/28/24 at 12:00 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments completed within the previous 15 months were in the resident's active record to allow access to licensed staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff have the knowledge and training necessary to adequately evaluate and provide for the nutritional needs of the residents. The failed practice had the ability to affect all 28 residents who received their meals from 1 of 1 facility kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure menus were followed to meet the nutritional needs of the residents. The failed practice had the ability to affect all 28 residents who receive their meals from 1 of 1 kitchen according to a list provided by the Administrator on 1/28/24 at 11:00 AM.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that hot foods were served at the temperature that is pleasing to the residents which improves palatability and encourages good nutritional intake. The failed practice had the ability to affect all 28 residents who receive their meals from 1 of 1 kitchen according to a list provided by the Administrator on 1/28/24 at 12:00 PM.

Inspectors wroteBased on observation and interview the facility failed to ensure t pureed foods was processed to the correct consistency to meet the needs of 2 (Residents #8 and #28) sampled residents who had a physician's order for a pureed diet according to a list provided by the Administrator on 2/1/23 at 9:07 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow requirements for prevention, detection, and control of water born illnesses including legionella disease. This failed practice had the potential to affect the entire building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the beside for 1 (Resident #13) to prevent accidental ingestion by other residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure documentation of communication with hospice services and to document hospice services in the resident care plan to ensure continuity of care for 1 (Resident #10) sampled resident who received hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in the freezer, refrigerator, dry storage area, and hall refrigerators were dated and distinguished between received and opened dates, failed to discard foods past their 'best by' dates, and failed to ensure the sanitization level was checked in the 3-compartment sink to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 29 residents (total census: 29) who receive meals from the Kitchen as documented by the Diet Roster provided by Administrator on 10/24/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was consistent with professional standards of care by ensuring Physician's Orders were followed, humidity bottles were not empty, and tubing and humidity bottles were dated to prevent potential respiratory complications for 2 (Resident #6 R #22) of 4 (R #6, R #10, R #18, and R #22) sample selected residents receiving oxygen. This failed practice had the potential to affect 6 residents who had Physician Orders for oxygen, per the Oxygen List provided by the Administrator on 10/27/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure written authorization for Advance Directive wishes concerning the right to accept or refuse medical or surgical treatment were signed by an authorized agent for 1 (Resident #16) of 7 (R #7, R #14, R #15, R #16, R #18, R #20, and R #26) sample selected residents. This failed practice had the potential to affect 61 new admissions since the facility's last annual recertification on [DATE] per the admission List provided by the Administrator on [DATE].

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident Assessments were coded correctly to ensure care areas were identified to provide needed care as evidenced by not coding Anticoagulant Medications for 2 (Resident #15 and #23) of 4 (#15, #16, #23, #26) sampled residents who received Anticoagulant Medications according to a list provided by the Minimum Data Set (MDS) Coordinator on 10/27/22.