Inspection Reports for
Concordia Nursing and Rehab, LLC
7 Professional Drive, Bella Vista, AR 72715, AR, 72715
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Deficiencies: 2
Date: May 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to baseline care plans for newly admitted residents and to verify that nurse aides were properly certified and had completed required background checks.
Findings
The facility failed to develop a baseline care plan within 48 hours of admission for one resident and failed to ensure that two nurse aides were certified in Arkansas and had completed required background checks. Minimal harm or potential for actual harm was noted for both deficiencies.
Deficiencies (2)
Failure to develop a baseline care plan for one resident within 48 hours of admission.
Failure to ensure Certified Nursing Assistants were certified in Arkansas and had completed background checks for two nurse aides.
Report Facts
Residents affected: 1
Residents affected: Many residents affected by nurse aide certification deficiency
Certification expiration date: Jan 31, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Mentioned in relation to lack of access to electronic health records and care plans |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Responsible for MDS and care plans, mentioned in baseline care plan deficiency |
| Registered Nurse #2 | Registered Nurse | Verified absence of baseline care plan and lack of EHR access |
| Certified Nursing Assistant #18 | Certified Nursing Assistant | Reviewed for certification and background check deficiencies |
| Certified Nursing Assistant #17 | Certified Nursing Assistant | Reviewed for certification and background check deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 20
Date: May 6, 2025
Visit Reason
The inspection was conducted as a recertification annual survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to post survey results accessibly, untimely and inaccurate Minimum Data Set (MDS) assessments, incomplete and untimely comprehensive care plans, lack of bed rail assessments and consents, inadequate fall prevention interventions, failure to provide appropriate care to maintain resident mobility, inadequate infection control practices including lack of PPE and improper catheter care, lack of full-time Director of Nursing and insufficient RN coverage, failure to maintain accurate and complete medical records, failure to provide required staff training including QAPI and compliance and ethics, and failure to maintain proper food safety and storage practices.
Deficiencies (20)
Failure to post the last survey results in an accessible location for residents' review.
Failure to complete Minimum Data Set (MDS) assessments timely for multiple residents.
Failure to ensure accurate MDS assessments, including bedrail and oxygen use coding.
Failure to develop and implement comprehensive person-centered care plans timely for multiple residents.
Failure to review and revise comprehensive care plans timely after falls and changes in condition.
Failure to provide appropriate care to maintain or improve resident mobility, resulting in immediate jeopardy.
Failure to provide proper fall assessments and interventions, resulting in immediate jeopardy.
Failure to implement dietary recommendations for residents with weight loss.
Failure to assess bed rail needs, obtain informed consent, and ensure proper installation and maintenance, resulting in immediate jeopardy.
Failure to ensure LPNs with IV certification managed PICC line care and IV medication administration, resulting in immediate jeopardy.
Failure to ensure a full-time Director of Nursing and adequate RN coverage, resulting in immediate jeopardy.
Failure to ensure Certified Nursing Assistants were properly certified and background checked.
Failure to maintain kitchen and food storage in sanitary condition, including expired food, unlabeled food, and unclean equipment.
Failure to administer the facility in a manner that enables effective and efficient use of resources, resulting in multiple immediate jeopardies.
Failure to safeguard resident-identifiable information and maintain complete and organized medical records.
Failure to provide a neutral and fair arbitration process including disclosure that signing is not a condition of admission and venue convenience.
Failure to provide and implement an infection prevention and control program including proper use of PPE and clean technique during wound and catheter care.
Failure to conduct and document a facility-wide assessment to determine necessary resources for competent resident care and emergency preparedness.
Failure to provide Quality Assurance and Performance Improvement (QAPI) training for all staff upon hire and ongoing in-services.
Failure to provide Compliance and Ethics training for all staff upon hire and ongoing in-services.
Report Facts
Days without RN coverage: 53
Number of falls: 22
Number of staff trained on bed rails: 24
Number of staff trained on falls: 18
Number of staff trained on QAPI: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in relation to MDS assessments and PICC line care. |
| RN #4 | Registered Nurse | Named as Interim Director of Nursing and involved in wound care. |
| Administrator | Named in relation to multiple findings including failure to post survey results, lack of DON, and failure to provide ownership disclosure. | |
| Assistant Director of Nursing | Named in relation to lack of DON responsibilities assumed and lack of knowledge of MDS and care plans. | |
| Medical Director | Named in relation to lack of involvement in care plans and orders. | |
| Certified Nursing Assistant #1 | CNA | Named in relation to infection control and fall interventions. |
| Housekeeping/Maintenance Supervisor | Named in relation to bed rail installation and maintenance. | |
| Certified Nursing Assistant #18 | CNA | Named in relation to certification and background check issues. |
| Certified Nursing Assistant #17 | CNA | Named in relation to certification and background check issues. |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident assessments, nutrition and dietary services, hospice care, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including unsafe medication practices, inadequate access to resident assessments, failure to address significant resident weight loss, insufficient dietary staff training and menu management, improper food handling and preparation, lack of proper infection control measures including Legionella management, and inadequate hospice communication and documentation.
Deficiencies (10)
Medications were left at the bedside for Resident #13, risking accidental ingestion.
Minimum Data Set (MDS) assessments were not maintained in residents' active clinical records, limiting licensed staff access.
Failure to promptly notify Medical Director and Registered Dietitian of progressive weight loss for Resident #21, resulting in actual harm.
Dietary staff lacked sufficient knowledge and training to meet residents' nutritional needs.
Menus were not followed as planned, substitutions were made without proper approval, and serving sizes were inconsistent.
Hot foods were served at temperatures below safe and palatable levels, with resident complaints about cold food.
Pureed foods were not processed to the correct consistency, risking choking hazards for residents requiring pureed diets.
Dietary staff failed to wash hands properly between tasks, used contaminated gloves, improperly handled utensils and food, and condiments were stored unsafely.
Failed to ensure documentation and communication of hospice services for Resident #10, affecting continuity of care.
Failed to implement infection prevention and control program for Legionella, including lack of water management team and testing.
Report Facts
Weight loss: 24
Weight loss: 19.8
Weight loss: 8.4
Food budget: 1450
Residents affected: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Asked about Minimum Data Set (MDS) assessments and hospice binder for Resident #10. |
| Director of Nursing | Director of Nursing (DON) | Involved in medication administration findings, MDS access issues, weight loss monitoring, and hospice communication. |
| Administrator | Facility Administrator | Provided policies, discussed dietary training and infection control, and addressed hospice communication. |
| Dietary Aide #1 | Dietary Aide / Dietary Manager candidate | Observed serving food, discussed training and menu substitutions, and food handling practices. |
| Dietary Manager | Dietary Manager | Discussed certification status, menu approval process, and food substitutions. |
| Registered Dietitian | Registered Dietitian (RD) | Described role, frequency of visits, and involvement in menu and weight meetings. |
| Dietary Employee #4 | Dietary Employee | Observed making peanut butter and jelly sandwich with contaminated gloves. |
| Infection Preventionist/ADON | Assistant Director of Nursing / Infection Preventionist | Interviewed about Legionella knowledge and water management program. |
| DE #1 | Dietary Employee | Observed food preparation, hand hygiene, and food serving practices. |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 4
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory requirements and ensure resident safety and care quality.
Findings
The facility was found deficient in several areas including improper authorization of advance directives, inaccurate resident assessments related to anticoagulant medication coding, inadequate respiratory care practices, and significant food safety and sanitation issues in the kitchen such as unlabeled and undated food items and lack of sanitization verification in the 3-compartment sink.
Deficiencies (4)
Failed to ensure written authorization for Advance Directive wishes were signed by an authorized agent for one resident.
Failed to ensure Resident Assessments were coded correctly for anticoagulant medications for two residents.
Failed to ensure respiratory care was consistent with professional standards, including following physician's orders and maintaining oxygen equipment properly for two residents.
Failed to ensure foods were properly dated, labeled, and stored, and failed to verify sanitization levels in the kitchen, risking foodborne illness for residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 29
Total census: 29
Advance Directive sample size: 7
Resident sample size for anticoagulant coding: 4
Resident sample size for oxygen care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Provided information on oxygen care and infection control practices during respiratory care deficiency finding |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, labeling, and sanitation practices in the kitchen |
| Dietary Employee #1 | Dietary Employee | Observed performing puree food preparation and sanitization checks in the kitchen |
| Administrator | Facility Administrator | Provided policies and responded to questions about Advance Directive authorization and sanitization documentation |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding medication coding for anticoagulants |
| Interim Director of Nursing | Interim DON | Commented on food labeling and storage practices in the kitchen |
| Business Office Manager | BOM | Interviewed regarding Advance Directive and POA documentation for Resident #16 |
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