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)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
356% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 19
Date: May 6, 2025
Visit Reason
The facility underwent a comprehensive annual survey to assess compliance with regulatory requirements including resident care, staffing, infection control, safety, and administrative oversight.
Findings
The survey identified multiple deficiencies including failure to post survey results accessibly, untimely and inaccurate Minimum Data Set (MDS) assessments, incomplete and untimely care plans, lack of proper bed rail assessments and consents, inadequate staffing including absence of full-time Director of Nursing and insufficient RN coverage, failure to properly manage PICC lines by non-IV certified LPNs, poor infection control practices including lack of PPE and improper catheter care, inadequate food storage and sanitation practices, incomplete medical records, and failure to provide required staff training including QAPI and compliance and ethics.
Deficiencies (19)
Failure to post the last survey results in an accessible location for residents.
Failure to complete Minimum Data Set (MDS) assessments timely for multiple residents.
Failure to ensure accuracy of MDS assessments related to bedrails and oxygen therapy.
Failure to develop and implement comprehensive person-centered care plans timely and revise them as needed.
Failure to assess and provide necessary equipment and interventions to maintain resident mobility, resulting in psychosocial harm.
Failure to provide proper assessments and interventions to prevent falls, resulting in multiple falls with injury.
Failure to implement dietary recommendations for residents with weight loss.
Failure to assess resident needs for bed rails, obtain informed consent, and ensure bed rails are compatible with beds.
Failure to ensure LPNs with IV certification managed PICC lines properly and lack of RN coverage for assessments.
Failure to employ a full-time Director of Nursing and ensure RN coverage for 8 consecutive hours daily.
Failure to ensure Certified Nursing Assistants were properly certified and background checked.
Failure to maintain kitchen sanitation, proper food storage, labeling, and separation of resident and employee food.
Failure to administer the facility in a manner that uses resources effectively and efficiently, including oversight of nursing services, bed rails, fall prevention, and resident mobility.
Failure to maintain organized medical records including physician orders, care plans, MDS, MAR, and TAR to ensure proper treatment and continuity of care.
Failure to provide a neutral and fair arbitration process including disclosure that signing arbitration is not a condition of admission and specifying venue for arbitration.
Failure to identify residents requiring Transmission Based Precautions (TBP) or Enhanced Barrier Precautions (EBP), failure to provide PPE, and failure to maintain clean technique during wound and catheter care.
Failure to conduct a thorough facility-wide assessment to determine staffing, training, emergency preparedness, and resource needs.
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
Falls: 22
Falls: 9
IV antibiotic doses: 17
Staff in-services on bed rails: 24
Staff in-services on QAPI: 0
Staff in-services on Compliance and Ethics: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in relation to incomplete MDS assessments and PICC line care. |
| RN #4 | Registered Nurse / Interim Director of Nursing | Named in relation to late MDS assessments and wound care. |
| Former DON #8 | Director of Nursing | Named in relation to failure to complete MDS assessments and care plans. |
| Administrator | Named in relation to multiple administrative failures including staffing, training, and disclosure. | |
| Medical Director | Named in relation to lack of involvement in care plans and system failures. | |
| Certified Nursing Assistant #1 | CNA | Named in relation to improper catheter care and infection control. |
| Assistant Director of Nursing | ADON | Named in relation to lack of assumption of DON duties and knowledge gaps. |
| Housekeeping/Maintenance Supervisor | Named in relation to bed rail installation and maintenance. | |
| Certified Nursing Assistant #18 | CNA | Named in relation to uncertified status and lack of knowledge of infection control. |
| Certified Nursing Assistant #17 | CNA | Named in relation to uncertified status and lack of background checks. |
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
Deficiencies: 2
Date: May 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to baseline care plans and nurse aide qualifications, including certification and 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.
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 failed to ensure background checks were completed for two nurse aides.
Report Facts
Residents affected: 1
Residents affected: Many
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
Routine
Deficiencies: 10
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident assessments, nutrition and dietary services, hospice care, infection control, and other aspects of resident care at Concordia Nursing & Rehab, LLC.
Findings
The facility was found deficient in multiple areas including medication safety, access to resident assessments, nutritional care and weight monitoring, dietary staff training and menu adherence, food safety and preparation, infection prevention, and hospice care documentation. Deficiencies ranged from minimal to actual harm, affecting residents' health and safety.
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 adequate training and certification to meet residents' nutritional needs.
Menus were not consistently followed or approved by the dietitian, and substitutions were made without proper oversight.
Hot foods were served at unsafe temperatures, and residents complained 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, used contaminated gloves, improperly handled utensils and food, and stored condiments unsafely, risking cross contamination.
Failure to ensure documentation and communication of hospice services for Resident #10 to maintain continuity of care.
Facility failed to implement an effective infection prevention and control program for Legionella disease, lacking 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 |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Asked about Minimum Data Set (MDS) assessments and hospice binder for Resident #10. |
| Director of Nursing | DON | Involved in medication administration findings, MDS access, weight monitoring, and hospice communication. |
| Dietary Aide #1 | Dietary Aide / Candidate Dietary Manager | Observed serving food, discussed training and certification plans, and food handling practices. |
| Dietary Manager | Dietary Manager | Discussed certification status, menu changes, food budget, and food preparation. |
| Registered Dietitian | RD | Described role, frequency of visits, and involvement in menu approval and nutritional assessments. |
| Administrator | Facility Administrator | Provided policies, discussed dietary training, hospice communication, and infection control. |
| Dietary Employee #4 | Dietary Employee | Observed preparing peanut butter and jelly sandwich with contaminated gloves. |
| Infection Preventionist/Assistant Director of Nursing | IP/ADON | Interviewed about Legionella disease knowledge and water management program. |
| Medical Director | Medical Director | Interviewed about awareness of resident weight loss and interventions. |
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 |
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 rights, accurate assessments, respiratory care, and food safety standards.
Findings
The facility was found deficient in multiple areas including failure to ensure proper authorization for advance directives, inaccurate resident assessments related to anticoagulant medication coding, inadequate respiratory care practices, and significant food safety violations such as improper food labeling, storage, and sanitation procedures.
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 provide safe and appropriate respiratory care by not following Physician's Orders, and not changing oxygen tubing and humidifier bottles timely for two residents.
Failed to ensure foods were properly dated, labeled, and stored, and failed to maintain sanitization levels in the kitchen, risking foodborne illness for residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 29
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DE #1 | Dietary Employee | Observed performing puree process and unable to verify sanitization levels due to lack of test strips |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding oxygen care and infection control practices |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, labeling, and sanitation practices |
| Administrator | Administrator | Provided policies and responded to questions about deficiencies |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding medication coding for anticoagulants |
| Interim Director of Nursing | Interim DON | Commented on food storage and labeling issues |
| Business Office Manager | Business Office Manager | Interviewed regarding Advance Directive and POA documentation |
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