Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On
10/18/2022 at 8:18 AM, V5, CNA, provided incontinent care while R2 in sit to stand, in R2's bathroom. V5
cleansed hands with hand sanitizer, and donned gloves. With R2 standing with the sit to stand, V5 took a
disposable wipe, and wiped one side of groin, folded the wipe then did other side of groin. V5 then used a
new disposable wipe and swiped from the front to the back of R2's perineal area. V5 did not separate labia
or dry after cleaning. V5 took same disposable wipe and rubbed over buttocks, did not dry R2, or place
moisture barrier cream on.
R2's MDS, dated [DATE], documents that R2 requires extensive assistance and two plus person physical
assistance for toileting.
R2's Care Plan, dated 10/13/2022, documents that R2 is frequently incontinent of urine. R2's Care Plan
documents the following interventions: check for incontinence, change if wet/soiled, cleanse with mild soap
and water. Apply moisture barrier as appropriate.
The facility's Perineal Care Policy, dated, 8/30/2022 documents Purpose: The purposes of this procedure
are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to
observe the resident's skin condition. Steps in the Procedure: 1. Perform hand hygiene. 2. Fill the wash
basin one-half full of warm water, if used. If not used, place perineal wipes within reach. 3. Put on gloves. 4.
For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe. b.
Wash perineal area, wiping from front to back. i. Separate labia and wash area downward from front to
back. ii. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra
down the catheter about three inches. If using soap and water, gently rinse and dry the area. iii. Continue to
wash the perineum moving from inside outward to and including thighs, alternating from side to side, and
using downward strokes. Do not reuse the same area of the washcloth and/or perineal wipe to clean the
urethra or labia. iv. If using soap and water, rinse perineum thoroughly in the same direction, using fresh
water and a clean washcloth, then dry perineum.
5. On 10/18/22 at 08:33 AM, during incontinent care R5 was on his back in bed. R5's incontinent brief was
wet as verified by V5, CNA and V10, CNA. V5, CNA, cleansed hands and donned gloves. V5 then used
disposable wipes to cleanse left side of groin, then right side of groin. V5 CNA then lifted penis and
cleansed scrotum. R5's scrotum was red in color. V5 did not retract and cleanse R5's penis. V5 did not dry
R5's area she just cleaned with wipes. V5 and V10 then turned R5 on left side. V5 CNA then took a wipe
and wiped from front to back. V5 did not cleanse inner thighs. Did not dry resident, did remove gloves
sanitize hands donned gloves and then applied barrier cream.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
146154
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146154
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia Village Care Center
4101 West Iles Avenue
Springfield, IL 62711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R5's care plan dated 4/1/2022 documents R5 is occasionally incontinent with intervention to check for
incontinence, change if wet/soiled. Clean skin with mild soap and water, Apply moisture barrier as
appropriate,
R5's MDS dated [DATE], documents R5 is always incontinent of urine. R5's MDS documents that R5
requires extensive assistance and two plus physical assistance for toileting.
The facility's Perineal Care Policy, dated, 8/30/2022 documents Purpose: The purposes of this procedure
are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to
observe the resident's skin condition. Steps in the Procedure: 1. Perform hand hygiene. 2. Fill the wash
basin one-half full of warm water, if used. If not used, place perineal wipes within reach. 3. Put on gloves. 5.
For a male resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe. b.
Wash perineal area starting with urethra and working outward. If the resident has an indwelling catheter,
gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and
dry the area. i. Retract foreskin of the uncircumcised male. ii. Wash using washcloth/soap or perineal wipe.
Then rinse, if using a washcloth and soap, urethral area using a circular motion. iii. Continue to wash the
perineal are including the penis, scrotum and inner thighs. Do not reuse the same area of the
washcloth/wipe to clean the urethra. c. Gently dry perineum following same sequence.
Based on interview, observation, and record review, the Facility failed to provide timely and complete
incontinent care for 5 of 6 residents (R2, R5, R14, R36, R27) reviewed for incontinent care in the sample of
22.
Findings include:
1. On 10/17/22 at 9:30 AM, R27 was lying in bed when V4, CNA, (Certified Nursing Assistant), and V5,
CNA, entered with a sit-to-stand device, to get R27 up to his wheelchair. The top sheets were pulled off
R27, showing his incontinent brief and his sheets saturated in urine. R27 assisted, to the toilet using a
sit-to-stand. After toileting, R27 was again stood up, using the sit-to-stand and a brief perineal care was
performed, by V5. Using the same gloves, she originally had on, V5 used a couple disposable wipes, then
wiped R27 once to the front perineal area. R27's penis, testicles, and buttocks were not cleansed, no
moisture barrier cream applied and R27 was not dried before applying the new incontinence brief.
R27's Care Plan, 10/14/22, documents (R27) is occasionally incontinent of bowel. Interventions: apply
moisture barrier to buttocks, assist to toilet for BM, (bowel movement), and check for incontinence. (R27) is
always incontinent of urine. Interventions: check for incontinence; change if wet/soiled. Clean skin with mild
soap and water, apply moisture barrier, check skin for redness, use pads/briefs to manage incontinence,
use positioning devices as needed.
R27's Minimum Data Set, (MDS), dated [DATE], documents that R27 has a severe cognitive impairment
and requires extensive assistance, from two people for bed mobility, transfers and dressing, requires
extensive assistance from one person for toilet use, personal hygiene and bathing. R27 is always
incontinent of urine and occasionally incontinent of bowel.
2. On 10/18/22 at 9:30 AM, V14, CNA, performed perineal care on R14 after raising R14 off the toilet using
a sit-to-stand. While R14 was standing, V14 reached from behind R14 and wiped once in-between her legs.
There was no cleansing of the right or left groin area in front, no moisture barrier
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146154
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146154
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia Village Care Center
4101 West Iles Avenue
Springfield, IL 62711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
cream applied, and no drying of R14 prior to putting a clean incontinence brief on.
Level of Harm - Minimal harm
or potential for actual harm
R14's Care Plan, dated 8/12/22, documents (R14) is frequently incontinent of urine. Interventions: Check
for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier, Dress in
clothing that is easily removed for toileting, implement safety measures, (keep path to bathroom clear and
well lit, select clothing that is easily removed for toileting, answer call bell quickly), Remind (R14) to empty
bladder before meals, at bedtime, and before activities. (R14) is frequently incontinent of bowel.
Interventions: Apply moisture barrier to buttocks, check for incontinence; clean and dry skin if wet or soiled,
Document when [NAME] is incontinent, Report areas of redness, Use pads/briefs to manage incontinence.
Residents Affected - Some
R14's MDS, dated [DATE], documents that R14 is cognitively intact and requires extensive assistance from
one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. R14 is
frequently incontinent of both bowel and bladder.
3. On 10/17/22 at 1:40 PM, V4, CNA, and V5, CNA, performed perineal care on R36. His pants were pulled
down and his saturated incontinence brief was removed and then was turned to his right side. V4 used two
disposable wipes and wiped once downwards to his left groin and then once to his right groin. V4 then
wiped around R36's uncircumcised penis and the underside of his penis but did not pull the foreskin back
and cleanse and did not clean his testicles. R36's left buttock/hip was wiped once and then he was rolled to
his back and a new incontinence brief was applied. There was no cleansing of R36's anal area, no
cleansing of his right buttock/hip, and no drying of R36 before applying new incontinence brief.
R36's Care Plan, dated 10/7/22, documents (R36) is always incontinent of bowel movement (no episodes
of continent bowel movement). Interventions: Apply moisture barrier to buttocks, check for incontinence;
clean and dry skin if wet or soiled, Document when (R36) is incontinent, Report areas of redness, Use
pads/briefs to manage incontinence. (R36) is always incontinent of urine. Interventions: Check for
incontinence; change if wet/soiled, clean skin with mild soap and water, apply moisture barrier, check skin
for areas of redness, report any changes to the nurse, use pads/briefs to manage incontinence, use
positioning devices as needed. It continues (R36) requires extensive assistance. Interventions: Provide
hygiene after voiding/BMs (bowel movement) to prevent skin breakdown, apply moisture barriers, select
clothing that is easily removed, change incontinence pad/brief.
R36's MDS, dated [DATE], documents that R36 has a severe cognitive impairment and is dependent on two
staff members for transfers, locomotion, dressing, toilet use, personal hygiene and bathing. R36 is always
incontinent of both bowel and bladder.
10/19/22 at 12:45 PM, V13, CNA, stated, When we get a resident up in the morning, we will do their
perineal care at that time.
On 10/19/22 at 1:15 PM, V2, DON, stated, I would expect the staff to provide complete and timely
incontinent care for all residents and follow the Care Plan for appropriate incontinent care needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146154
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146154
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia Village Care Center
4101 West Iles Avenue
Springfield, IL 62711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on interview, observation, and record review, the facility failed to safely secure and store medications
in a locked medication cart, failed to dispose of expired medications in the medication cart, and failed to
properly label medications with a resident name and the open date. These failures have the potential to
affect all 44 residents in the facility.
Findings include:
1. On 10/17/22 at 11:20 AM, the medication cart located on the 6200 hall, (Reach), was seen unlocked with
no nurse in sight. No residents were seen around the cart. V7, RN, (Registered Nurse), was working this
hall and caring for residents.
2. On 10/18/22 at 2:45 PM, the medication cart located on the 6300 hall, (Summer Breeze), was seen
unlocked with two unattended residents, R38 and R10, sitting in their wheelchairs about six to ten feet away
from the cart.
3. On 10/18/22 at 9:00 AM, The medication cart on the 6200-hall had four expired cards of medications for
R14. These include Baclofen 10 mg, (Milligram), expired 8/10/22 with 14 LTC, (Left to Count), Levothyroxine
112 mcg, (Microgram), expired 8/1/22 with 4 LTC, Celecoxib 100 mg, expired 8/9/22 with 9 LTC,
Gabapentin 400 mg expired 8/9/22 with 11 LTC.
On 10/18/22 at 9:10 AM, V11, RN, (Registered Nurse), stated (R14) came in with these medications and
we don't use them, we use the roll packs from our pharmacy. They should have been discarded.
4. The Medication, (Nurse's), room with a locked refrigerator and medications inside had a stock vial of
Tuberculin opened with no open date, there was a vial of Humulin R Insulin 100units/ml, (Milliliter), opened,
not labeled with a resident's name or the date opened. There was a vial of Humalog Insulin 100units/ml
opened and not labeled with a resident's name or the date opened, along with, two Humalog Insulin pens
100units/ml opened and not labeled with a resident's name, or the date opened, and a Lantus Insulin pen
100units/ml opened and not labeled with a resident's name or date opened.
On 10/18/22 at 9:20 AM, V11, RN, stated I know the insulins were (R193's), because he is the only one on
Insulin. We have two residents who are Diabetic and only (R193) is on Insulin. Yes, they should have been
labeled, but I can't control what other staff do.
On 10/19/22 at 1:17 PM, V2, DON, (Director of Nursing), stated I would expect the nurses to keep the
medication carts locked at all times, to dispose of or send back to pharmacy any expired medications, to
label all open vials with the date it was opened, and to label all vials/medications with the resident's name.
Then on 10/18/22 at 9:30 AM, V11 was then seen labeling each Insulin Pen with a yellow sticky note with
R193's name written on it.
The Facility's Labeling and Storage of Medications, dated 5/26/21, documents All medication maintained in
the community will be properly labeled in accordance with current State and Federal regulations and stored
in a safe, secure, and orderly manner. Labeling: 1. Medication labels must be legible at all times. 2. Labels
for individual medication containers shall include all necessary information such as: a. The resident's name;
b. The prescribing physician's name; c. The name, address, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146154
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146154
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia Village Care Center
4101 West Iles Avenue
Springfield, IL 62711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
telephone number of the issuing pharmacy; d. The name and strength and quantity of the medication; e.
The prescription number (if applicable); f. The date the medication was dispensed; g. Appropriate accessory
and cautionary statements; h. The expiration date, when applicable; and i. Directions for use. 3. Labels for
each single unit dose package shall include all necessary information, such as: a. The name and strength
of the medication; b. The lot and/or control number; c. Appropriate accessory and cautionary statements; d.
The expiration date, when applicable; e.
The name of the resident and physician (Note: The names of the resident and physician do not have to be
on each unit package, but they must be identified with the package in such a manner as to ensure that the
medication is administered to the right resident); f. The prescription number; g. The name, address, and
telephone number of the pharmacy dispensing the medication; and h. Directions for use. It continues
Storage: 3. Medication containers that have missing, incomplete, improper, or incorrect labels should be
returned to the dispensing pharmacy or destroyed. 4. The community will not use discontinued, outdated, or
deteriorated medications. All such medications will be returned to the dispensing pharmacy or destroyed. 6.
Compartments (including but not limited to: drawers, cabinets, rooms, refrigerators, carts, and boxes)
containing medications shall be locked when not in use, and trays or carts that transport such items should
not be left unattended if open or otherwise potentially available to others.
The Facility's CMS 672, dated 10/17/22, documents that there are 44 residents residing in this facility at this
time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146154
If continuation sheet
Page 5 of 5
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the October 20, 2022 survey of CONCORDIA VILLAGE CARE CENTER?
This was a inspection survey of CONCORDIA VILLAGE CARE CENTER on October 20, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CONCORDIA VILLAGE CARE CENTER on October 20, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have simulated fire drills held at unexpected times."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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