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Inspection visit

Inspection

CONCORDIA VILLAGE CARE CENTERCMS #1461544 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies, 1 of them serious (actual harm or immediate jeopardy). 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** Based on observation, interview, and record review, the facility failed to provide complete incontinence care for 4 of 4 (R6, R19, R36, R41) residents reviewed for incontinent care in a sample of 13. Findings include: 1. R6's Care Plan, last evaluation date 9/19/23, documents R6 is always incontinent of urine and frequently incontinent of bowel. It also documents, check for incontinence; clean and dry skin if wet or soiled. R6's Minimum Data Set/MDS, dated [DATE], documents R6 is severely cognitively impaired, always incontinent of bowel and bladder, and is totally dependent on 2 staff for toileting. On 9/19/2023 at 1:40 PM, V11, V13, and V16, all CNAs (Certified Nursing Assistants), assisted R6 with incontinent care. V11, V13, and V16 transferred R6 into the bed using the full body lift. V11, V13, and V16 rolled R6 onto his left side and removed his pants, then assisted to R6 to R6's back. V16 opened R6's incontinent brief. V11, V13, and V16 turned R6 onto his right side, and V16 removed R6's incontinent brief which was soiled with stool. V13, using a wet wipe, cleansed R6's anal area x3. V16 then applied the clean incontinent brief behind R6. V11, V13, and V16 turned R6 onto his right side, and V11 pulled the clean brief onto R6's buttocks. V11, V13, and V16 rolled R6 onto his back. Using a wet wipe, V16 wiped R6 penis. V11, using a wipe, cleaned R6's right and left groin and penis. V16 closed R6's incontinent brief. V11, V13, and V16 stated they were finished with incontinent and peri care at that time. V13 did not cleanse R6 buttocks, and V11 and V16 did not cleanse R6's scrotum or shaft of R6's penis. 2. R19's Care Plan, last evaluation date 8/22/23, documents R19 has ADL (activity of daily living) selfcare deficit related to decreased mobility and muscle weakness. (R19) requires extensive assist with most ADLs. It also documents R19 is always incontinent. It continues, check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier as appropriate. R19's MDS, dated [DATE], documents R19 is always incontinent of urine and requires extensive assist of 1 staff member for toileting. On 09/18/23 at 1:30 PM, V11, CNA, assisted R19 with toileting. R19 was incontinent of urine. V11 assisted R19 to the toilet using the standup lift. V11 removed R19's incontinent brief and heavily soiled incontinent insert. V11 sat R19 onto the toilet; R19 voided. V11 stood R19 up and cleansed R19 anal area, using a wipe. V11, standing behind R19, went between R19 legs from behind and wiped the (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 11 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 09/21/2023 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 vaginal area twice. V11 applied a new brief and assisted R19 back into her wheelchair. V11 did not cleanse R19's buttocks, groin area, inner thighs, or inner labia. 3. R31's Care Plan, last evaluation date 6/28/2023, documents R31 is frequently incontinent of bowel and bladder. It also documents, check for incontinence, change if wet/soiled. Clean with mild soap and water. Apply moisture barrier. R31's MDS, dated [DATE], documents R31 is frequently incontinent of urine and occasionally incontinent of bowel, and requires extensive assist of 1 person for toileting. On 9/20/23 at 1:24 PM, V11 and V13 assisted R31 with toileting. R31 was incontinent of urine. V11 and V13 assisted R31 into the bed using a mechanical lift. V11 and V13 removed R31's pants, revealing a heavily soiled brief and soiled pants. V11 and V13 rolled R31 onto her right side. V11, using a wet wipe, cleansed R31's left buttock, rolled the soiled brief under R31, and placed a clean brief behind R31. V11 and V13 rolled R31 onto her back and cleansed R36 right and left groin and outer labia. V11 and V13 rolled R31 onto her left side, removed soiled brief, and pulled a clean brief under R31. V11 and V13 rolled R31 onto her back and closed the brief. V11 and V13 failed to clean R31's entire left buttock or right buttock, inner labia, vaginal area, and inner thighs. On 9/20/2023 at 3:15 PM V2, Director of Nursing, stated the Perineal Care policy is the same as the incontinent care policy. On 9/20/2023 at 3:17 PM, V22, Registered Nurse, stated she expects the CNAs to clean all areas of incontinence when providing incontinent care. V22 stated, For a female, this includes the inner labia, vaginal area, both buttocks, and inner thigh. For a male, the penis, shaft, scrotum, beneath the scrotum, both buttocks, and inner thighs. If a resident is incontinent and then placed on the toilet, I expect the staff to perform incontinent care even if the resident then voids on the toilet. V22 stated she would expect the staff to wash their hand before putting on gloves, and when changing gloves to use hand sanitizer. On 9/20/23 at 3:19 PM V23, CNA, stated, When cleaning an incontinent resident, you clean all the areas that would come in contact with the urine. This would include the vaginal area, inner labia, groin, scrotum, both buttocks and inner thigh. If a resident is incontinent, they receive incontinent care regardless. V23 stated when putting on gloves, hand hygiene is performed first. V23 stated this could be soap and water or hand gel. 4. R36's Care Plan, last evaluation date 9/14/2023, documents R36 is frequently incontinent of bowel and bladder. It also documents, Check for incontinence, change if wet/soiled. Clean with mild soap and water. Apply moisture barrier. R36's Minimum Data Set, (MDS), dated [DATE], documents R36 is severely cognitively impaired, always incontinent of urine, frequently incontinent of bowel, and requires extensive assist of 1 staff for toileting. On 09/18/23 at 1:51 PM, V11 and V12, Certified Nursing Assistants, (CNAs), assisted R36 with toileting. R36 was incontinent of urine. V11 and V15 (Licensed Practical Nurse/LPN) used the standup lift to transfer R36 to the toilet. V12 removed R36's urine soiled brief. V11 and V12 stood R36, and V11, using a wipe, cleansed R36 anal area, with stool on wipe. V11 and V12 sat R36 on toilet. At 1:55 PM, V11 and V12 stood R36. V11, using a wipe, cleansed R36 anal area. V11 cleansed R36's right groin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 2 of 11 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 09/21/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete area from the back. V11 cleansed R36's penis. V11 did not cleanse R36's left groin, scrotum, or R36's right and left buttock. The facility's Perineal policy, dated 8/30/22, documents, The purpose 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. 4. For female b. wash perineal area wiping front to back. i. Separate and wash area downward from front to back. iii. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. C. Wash the rectal area thoroughly, using a washcloth or perineal wipe, wiping from the base of the labia towards and extending over the buttocks. 5. For male b. Wash the perineal area starting with urethra and working outward. Iii. Continue to wash the perineal area including the penis, scrotum, and inner thighs. e. Wash and rinse, or use perineal wipe, the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. Event ID: Facility ID: 146154 If continuation sheet Page 3 of 11 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 09/21/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm 2. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. Residents Affected - Few R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. Indication was for glaucoma. Every evening starting 9/11/23 at 5:00 PM. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. On 09/19/2023 at 08:37 AM, V5, Registered Nurse, (RN), was at the medication cart; took out R104's Latanoprost eye drops. V5 administered R104's latanoprost eye drops, 1 drop in each eye. On 09/20/2023 at 10:43 AM, R104 stated he was ok with the nurse (V5, RN) giving him his eye drops at the breakfast table. He continued to state usually they do his eye drops in his room. On 09/20/2023 at 11:25 AM V14, RN stated she would give the right medication at the right time as ordered. On 09/20/2023 at 2:00 PM, V7, LPN stated she would give the right medication at the right time. On 09/20/2023 2:15 PM, V21, LPN stated would give the right medication at the right time and as the Doctor ordered it. The Facility's Administering Medication Policy, dated 9/22/2023, documents, Medication shall be administered in a safe and timely manner as prescribed. Based on interview and record review, the facility failed to ensure medications were given as prescribed, as well as at the time frame as ordered, for 2 of 5 residents, (R32, R104) reviewed for medications, in the sample of 28. This failure caused R32's medication to be omitted for 5 doses/nights, causing R32 to experience wandering behaviors requiring intervention. Findings include: 1. R32's Face Sheet, dated 9/20/2023, documents R32 has Alzheimer's Disease, Dementia with Behavioral Disturbances, Insomnia, and Hallucinations. R32's Administration Record documents, Trazodone 100 mg, (Milligrams), tablet one time daily starting 12/23/2022. Indication: Insomnia. R32's Care Plan, dated 9/20/2023, documents, (R32) has a diagnosis of Insomnia- Alteration in sleep pattern related to insomnia. Medications should be given per the Medical Doctor's order. The Facility's Adverse Event Documentation, dated 3/27/2023, documents, Brief Description of Medication Event (describe medications involved and any immediate actions taken). On 3/26/2023 it was noted that Trazodone 100 mg was not in the medication strip. Call placed to Pharmacy who states the medication was not discontinued on 3/16/2023. Our records indicate that medication as not discontinued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 4 of 11 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 09/21/2023 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 0760 Level of Harm - Actual harm but was updated to add Physical monitors to the order. Pharmacy states, they did not receive the updated order. Pharmacy confirms that Trazodone was delivered on 3/15/2023 with enough meds to receive doses through 3/21/2023. Resident did not receive Trazodone as ordered from 3/21/2023-3/25/2023. Trazodone 50 mg 2 tabs were pulled from the state safe for 2100 (9 PM) dose on 3/26/2023. No adverse effects noted. Residents Affected - Few R32's Administration History documents R32 had no behaviors requiring intervention 3/16/2023, 3/17/2023, 3/10/2023, 3/20/23. Its further documents on 3/21/2023, R32 exhibited wandering behaviors on 3/21/2023, 3/22/2023, and 3/24/2023 requiring redirection, and one to one staff with resident. On 9/19/2023 at 11:56 AM, V24, Certified Nursing Assistant, (CNA), stated she has worked at the Facility for approximately one year. V24 stated R32 does not currently have any behaviors, but he did previously. V24 stated, He (R32) wouldn't sleep. He was an 'all nighter' (implying R32 stayed up all night). On 9/20/2023 at 1:02 PM, V17, Assistant Director of Nursing, (ADON), stated, We added Physical monitors for adverse reactions or behaviors (to the Administration History). I faintly remember the Trazodone situation. The nurses should have noticed it wasn't there if they were following the MAR (Medication Administration Record). I do not know how they did not catch it for that many days. That's the problem. It (Trazodone) wasn't being given. On 9/20/2023 at 1:17 PM, V17 stated R32 could have experienced some adverse effects from missing the Trazodone doses. On 9/20/2023 at 1:59 PM V2, Director of Nursing, (DON), stated, The nurses obviously didn't check to make sure it was packaged in the (medication) strips. I would expect them to check every single time for medication accuracy. If a med (medication) was missing, I would expect them to notify Pharmacy and get it out of the stat safe (an emergency medication supply). V2 continued to state the Facility had implemented a new behavior tracking system and the medication order had to be discontinued and re-entered. V2 stated, The Pharmacy reports they did not get the new order entered, just to discontinue it. V2 stated, He (R32) did exhibit increased symptoms (restlessness) during that time frame (3/21/2023-3/25/2023). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 5 of 11 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 09/21/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure medications appropriately, and failed to label and date open bottles of medications. The facility also failed to ensure medications requiring refrigeration were monitored and documented per the Facility policy. This has the potential to affect all 49 residents living in the facility. Findings include: 1. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams, (mg)-timolol 6.8 mg/milliliters, (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, the rehabilitation hall medication cart was in the hallway and was unlocked. V5, Registered Nurse (RN), was in the dining area. On top of the cart was a box of Enoxaparin 40mg/0.4ml box with 5 filled syringes in it, belonging to R47. At 8:43 AM, V5 walked away from the medication cart, leaving it unlocked, to take R104's Blood Pressure. R104 was out in the dining room. V5, RN, returned to the medication cart, took out R104's medication: Dorzolamide 22.3 milligrams, (mg), -timolol 6.8 mg/milliliters, (ml), eye (1 drop) both eyes. This bottle was open and was not dated. V5, RN, then left the medication cart, out in the hallway, and walked away from it without locking it to give R104 his medication. On 09/20/2023 at 10:43 AM, R104 stated usually they give him his eye drops in his room. 2. R102's Face sheet, dated 9/20/2023, documented diagnoses of displaced spiral fracture of the left femur. R102's MDS, undated, documented her cognition was intact. R102's Physicians order sheet, dated 09/2023, documented an order for enoxaparin 40mg/0.4ml syringe subcutaneous one time daily. Docusate 100 mg capsule two times daily, Donepezil 10 mg tablet one time daily, Magnesium Oxide 400mg tablet one time daily, Oyster Shell Calcium-Vitamin D3 500mg- 5 micrograms (mcg) two times daily, [NAME] Colon Health 3 billion cell capsule 1 capsule one time daily, Sertraline 50mg tablet one time daily, Vitamin D3 25 mcg capsule one time daily and Multiple VitaminMinerals tablet one time daily. There was not an order documented for resident to self-administer medications. On 9/19/2023, V5, RN, returned to the medication cart, that was still unlocked, and removed R102's medications. V5, RN, left the medication cart unlocked and walked away. R102 was sitting at the dining room table with R47 and V6, R47's husband. V5, RN, handed R102 her pill cup with her medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 6 of 11 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 09/21/2023 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 in it, and walked away not observing her taking them. Level of Harm - Minimal harm or potential for actual harm On 09/20/2023 at 1000 AM, R102 stated they do leave her medication with her at the table because she takes it with food. Residents Affected - Many 3. R101's Face sheet, dated 9/20/23, documented diagnoses of Sepsis and Chronic Obstructive Pulmonary Disease, (COPD). R101 was admitted to the facility on [DATE]. R101's Physicians Order sheet, dated 9/2023, documented an order for Carboxymethylcellulose sodium 0.5% eye drops (Refresh Plus eye drops) 1 drop both eyes indication dry eyes as needed starting 09/12/2023. It did not document this medication could be left at the resident's bedside. On 9/19/2023 at 9:00 AM, V5, RN, took out the medication packages for R101. V5 stated she needed to take R101's blood pressure, and she put the medicine packages back in the medication cart, did not lock the cart, and went into R101's room. On R101's overbed table, was Refresh plus eye drops box with 10 disposable vials of eye drops. There was not a Pharmacy label, nor was it dated. V5 returned to the unlocked medication cart, took R101's medication out of the packages and placed them on top of the medication cart, and placed them in a medication cup. V5 then walked away from the unlocked medication cart, and entered R101's room. V5, RN, administered the Refresh plus eye drops that were on the overbed table to R101, and gave him his medication. On 09/20/2023 at 10:13 AM, R101 stated he did not know who brought the eye drops in that were on his overbed table. On 09/20/2023 at 11:25 AM, V14, RN stated she would lock the medication cart when she is giving medications or when it is not in use. V14 also stated she does not have any residents with orders to leave their medications at the bedside, and when she gives medications, she stays with the resident until all their pills are taken. On 09/20/2023 at 2:00 PM, V7, License Practical Nurse, (LPN), stated she would keep the medication cart locked at all times if she was not getting meds out of it, or when she leaves it unattended to go give a resident their medication. She stated the medication cart stays out in the hallway when not in use, and no medicines are left on top of it. The only medications that can be left at a resident's bedside are the ones that have a doctor's order to do so. On 09/20/2023 at 2:15 PM, V21, LPN stated her medication cart is always locked when she is not using it, and when it is out in the hallway. She stated it is also locked when she is giving a resident their medication. V21, LPN, stated she would wash her hands and don gloves when giving injections and eye drops. She does not have any residents that have orders to keep medications at the bedside, and medications cannot be left with the resident to be taken without her there. On 09/20/2023 at 3:10 PM, V3, Assistant Administrator, statedshe would expect staff to lock the medication cart and not leave medications at the bedside without an order. On 09/20/2023 at 3:15 PM, V2, Director of Nursing, stated she would expect staff to lock the medication cart and not leave medications at the bedside without an order. V2 also stated she would expect the nurses to stay with the resident to make sure they take their medicine. 4. On 9/19/2023 at 10:09 AM, the medication storage room was inspected. There was a refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 7 of 11 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 09/21/2023 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 containing medications. V8, Licensed Practical Nurse, (LPN), stated, The temperatures are only checked once a day and it's done on night shift. It is documented in this binder. The Facility's Refrigerator and Freezer Temp, (temperature)/Humidity Log, dated September 2023, was reviewed and contained several days without a temperature documented, including 9/4/2023, 9/8/2023, 9/9/2023, 9/13/2023, 9/17/2023, and 9/18/2023. V8 verified this information by stating, There are a couple night shift entries missing. Residents Affected - Many On 9/19/2023 at 10:15 AM, V17, Assistant Director of Nursing, (ADON), stated, Refrigerator temperatures should be taken and recorded once a day. 5. On 9/19/2023 at 10:10 AM, the refrigerator in the Summer Breeze Household was inspected. At this time, a vial of Humalog with a small yellow paper taped to the vial that said, (105's name). There was no date opened sticker on the vial. The vial had been opened, and contained about half of the insulin remaining. At this time, V8 verified the vial had been opened and stated, (R105) isn't even on this hall. He is on (another household). On 9/20/2023 at 1:59 PM, V2, Director of Nursing, (DON), stated, Of course I would expect it (the insulin vial) to be dated (to indicate when it had been opened). On 9/21/2023 at 11:08 AM, V25, Pharmacist, stated Humalog should be discarded after 28 days of the vial being open. The Facility's Medication Storage in the Facility Policy, dated March 2021, documents, Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. It continues to document, B. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when not in use or in direct view of persons with authorized access. If further documents, Temperature: E. The Facility should maintain a temperature log in the storage area to record temperatures at least once a day. It further documents, Expiration Dating (Beyond-use dating): D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication (if dedicated area not on label/container) and enter the date opened and the new expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date of regulations/guidelines require different dating. The Facility's Administering Medication Policy, dated 9/22/2023, documents, Medication shall be administered in a safe and timely manner as prescribed. It continues to document, The expiration date/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose injectable (i.e insulin), the date opened shall be recorded on the container. It further documents, During administration of medications, the medication cart will be kept closed and locked when out of sight of the individual administering medications. The Resident Census and Conditions of Residents, CMS 672, dated 09/19/2023, documents the facility has 49 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 8 of 11 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 09/21/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene and donning gloves during medication administration and incontinent care and, and failed to perform appropriate cleaning of soiled surfaces for 4 of 6 (R31, R101, R102 R104) residents reviewed infection prevention, in a sample of 28. Residents Affected - Some Findings include: 1.R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented his cognition was moderately impaired. R104's Physician Order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams (mg)-timolol 6.8 mg/milliliters (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, V5, Registered Nurse, (RN), statedshe spilled Metamucil granules on top of the medication cart. V5 retrieved a dry paper towel and wiped off the cart, leaving granules in the crevasses of the medication cart. V5, RN, took out R104's medication packages and opened them up onto the top of the medication cart where the Metamucil granules were. Then, without benefit of hand hygiene, V5 placed medications, with her bare hands, into a medication cup. V5, without benefit of hand hygiene or donning gloves, administered R104's latanoprost eye drops, administered R104's pills, and administered R104's Dorzolamide 22.3 milligrams (mg)-timolol 6.8 mg/milliliters (ml) 1 drop in each eye. 2. R102's Face sheet, dated 9/20/2023, documented diagnoses of displaced spiral fracture of the left femur. R102's MDS, undated, documented her cognition was intact. R102's Physicians Order Sheet, dated 09/2023, documented an order for enoxaparin (Lovenox) 40mg/0.4ml syringe subcutaneous one time daily. Docusate 100 mg capsule two times daily, Donepezil 10 mg tablet one time daily, Magnesium Oxide 400mg tablet one time daily, Oyster Shell Calcium-Vitamin D3 500mg- 5 micrograms (mcg) two times daily, [NAME] Colon Health 3 billion cell capsule 1 capsule one time daily, Sertraline 50mg tablet one time daily, Vitamin D3 25 mcg capsule one time daily and Multiple VitaminMinerals tablet one time daily. There was not an order documented, for resident to self-administer medications. On 9/19/2023, V5, RN, returned to the medication cart, that was still unlocked, and without benefit of hand hygiene, she took R102's medications, Lovenox 40mg/0.4ml injectable, Docusate, Donepezil, Magnesium Ox, Oyster Shell, [NAME] Colon Health, Sertraline, Vitamin D and Theran M + out of the packages with the pills landing on top of the medication cart. With her bare hands, she then placed the medications into a medication cup. R102 was sitting at the dining room table. V5, RN, used alcohol-based hand rub (ABHR), went to R102's dining room table, and without donning gloves, she lifted up R102's shirt to expose her right mid abdomen, used an alcohol wipe and cleansed her right abdomen, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 9 of 11 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 09/21/2023 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 0880 injected R102 with her Lovenox 40mg/0.4 ml to that area. Level of Harm - Minimal harm or potential for actual harm 3. R101's Face sheet, dated 9/20/23, documented diagnoses of Sepsis and Chronic Obstructive Pulmonary Disease. R101 was admitted to the facility on [DATE]. Residents Affected - Some R101's Physicians Order Sheet, dated 9/2023, documented, an order for Carboxymethylcellulose sodium 0.5% eye drops (Refresh Plus eye drops) 1 drop both eyes indication dry eyes as needed starting 09/12/2023. It did not document that this medication could be left at the resident's bedside. On 09/20/2023 at 9:00 AM, V5, RN, took out the medication packages for R101's Fluoxetine, Lasix, healthy eyes cap, spironolactone, EC ASA, Carvedilol, Docusate, K+, Eliquis, Enestrol, and without benefit of hand hygiene, took the above medication out of the packages and placed them on top of the medication cart. Then with her bare hands and without benefit of hand hygiene, V5 picked up the medications and placed them in the med cup. V5, RN, entered R101's room, and without benefit of hand hygiene or without donning gloves, administered the Refresh plus eye drops to R101, and gave him his medication. On 09/20/2023 at 11:25 AM, V14, RN, stated she would never open the pill package and put the medicines on top of the cart if the cart had something spilled on it. V14 stated she would wash her hands and put on gloves when she is giving an injection or eye drops to a resident. On 09/20/2023 at 2:00 PM, V7, Licensed Practical Nurse, (LPN), stated she would wash her hands and put gloves on when giving a resident an injection, and if she spilled something on the medication cart, she would clean it up with Sani wipes or soap and water. She stated she does not open the resident's medication packets and put the pills on top of the medication cart. She would open the pill package and put them in the med cup. On 09/20/2023 at 2:15 PM V21, LPN, stated she if she spilled something on top of her medication cart, she would clean it up with the sanitizing cloths or soap and water, and she does not put open pills on top of the cart; she puts them in a medicine cup. V21, LPN stated she would wash her hands and don gloves when giving injections and eye drops. On 09/20/2023 at 3:10 PM, V3, Assistant Administrator stated she would expect the staff to wash their hands and wear gloves when giving injections and eye drops. V3 stated she would expect the staff to clean off the top of the med cart with the appropriate cleaner. On 09/20/2023 at 3:15 PM, V2, Director of Nursing, stated she would expect the staff to wash their hands and wear gloves when giving injections and eye drops. V2 stated she would expect the staff to clean off the top of the med cart with the appropriate cleaner. 4. R31's MDS, dated [DATE], documents R31 is severely cognitively impaired, frequently incontinent of urine, and occasionally incontinent of bowel, and requires extensive assist of 1 person for toileting. On 9/20/23 at 1:24 PM, V11 and V13 assisted R31 with toileting. R31 was incontinent of urine. V11 and V13 assisted R31 into the bed using a mechanical lift. V11 applied gloves; no hand hygiene performed. V11 and V13 removed R31's pants revealing heavily soiled brief and soiled pants. V11 removed her gloves and applied new ones; no hand hygiene performed. V11 and V13 rolled R31 onto her right side. V11, using a wet wipe, cleansed R31's left buttock, rolled the soiled brief under R31, and placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 10 of 11 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 09/21/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a clean brief behind R31. V11 removed her gloves and applied new ones; no hand hygiene performed. V11 and V13 rolled R31 onto her back and cleansed R36 right and left groin and outer labia. V11 and V13 rolled R31 onto her left side. V13 removed the soiled brief and pulled the clean brief under R31. V11 removed her gloves. V11 and V13 rolled R31 onto her back and closed the brief. V13, using the same soiled gloves, pulled R31's linen over R31, and moved the bed against the wall. V13 removed her gloves and left the room. V11 gathered soiled linens and placed them in the soiled utility room. V11 and V13 did not perform hand hygiene up completion of incontinent care. On 9/20/2023 at 3:15 PM, V2, Director of Nursing, stated the Perineal Care policy is the same as the incontinent care policy. On 9/20/2023 at 3:17 PM, V22, Registered Nurse, V22 stated she would expect the staff to wash their hands before putting on the gloves, and when changing gloves to use hand sanitizer. On 9/20/23 at 3:19 PM, V23, CNA, stated V23 stated when putting on the gloves hand hygiene is performed first. V23 stated this could be soap and water or hand gel. The facility's Perineal policy, dated 8/30/22, documents, the purpose 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. 1. Perform hand hygiene. 3. Put on gloves. 6. Remove gloves. 7. Perform hand hygiene. The facility's Hand Hygiene policy, dated 9/23/22, documents, This organization considers hand hygiene the primary means to prevent the spread of infections. 7. Use and alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 11 of 11

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Citations

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.

  • 0760SeriousS&S Gactual harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0690GeneralS&S Epotential for harm

    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.

  • 0761GeneralS&S Fpotential for harm

    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.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the September 21, 2023 survey of CONCORDIA VILLAGE CARE CENTER?

This was a inspection survey of CONCORDIA VILLAGE CARE CENTER on September 21, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CONCORDIA VILLAGE CARE CENTER on September 21, 2023?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."

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

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