Inspection·June 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely assessment and treatment of humeral fracture in 1 of 3 residents (R2) reviewed for abuse in the sample of 3. Residents Affected - Few This failure resulted in a delay of care for R2's humeral fracture from, at a minimum, 5:30 PM on 6/12/24 to 12:34 PM on 6/13/24. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE], with diagnoses including dementia, depression, muscle weakness, osteoporosis, and history of falling. R2's, undated, Minimum Data Set/MDS documented R2 was severely cognitively impaired with inattention, disorganized thinking, and altered level of consciousness. The MDS documented R2 ambulated via wheelchair, required substantial assistance with rolling, and was dependent with transfer. R2's Care Plan, starting 3/29/24, documents R2 is at risk for falls, injury, and pain. On 6/25/24 at 1:43 PM, V7, Certified Nursing Assistant (CNA), stated, (R2) complained of right arm pain before getting up on the morning of 6/12/24 and was not using her right arm at lunch time, which she usually uses to feed herself. On 6/25/24 at 2:58 PM, V8, Registered Nurse, (RN) stated several people commented to her that R2 was not her usual perky self on 6/12/24. She stated V7, CNA, mentioned to her in the afternoon that R2 had complained of right arm pain earlier in the day, but when V8 checked in on R2, she was sleeping peacefully in her bed. On 6/25/24 at 3:15 PM, V9, CNA, stated he cared for R2 on the evening of 6/12/24, and noticed R2 was not using her right arm during dinner. He stated, (R2's) right arm was hanging in an unusual way, then I noticed bruising while getting her ready for bed. V9 stated he informed V20, Licensed Practical Nurse, (LPN), and she stated she would let the other nurses know. On 6/26/24 at 8:35 AM, V20, Licensed Practical Nurse, (LPN), stated she was walking out the door to leave work, around 5:30 PM on 6/12/24 when V9, CNA, came and asked her if she knew anything about a bruise on R2. She stated she was unaware of any bruising, but told V9 he should check with the other nurses and see if there was any documentation in the Shift Change Report Notes. On 6/26/24 at 9:06 AM, V15, LPN, stated she cared for R2 on 6/13/24, and V9, CNA, did not report (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 3 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 06/26/2024 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)