Inspection visit
Health inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Based on observation, staff interviews and review of facility policy, the facility failed to provide dining assistance during with meals in a dignified manner when staff stood up while feeding residents. This affected one (Resident #27) of two residents reviewed for dining assistance. The facility census was 40.
Findings include: Review of Resident #27's medical record revealed an admission date of 09/13/19. Diagnoses included cerebral vascular accident (CVA), dysphasia, hemiplegia, diabetes mellitus, and congestive heart failure. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the resident had low cognitive function. The resident required supervision and set up assistance with eating. Observation on 04/20/22 at 8:09 A.M. revealed State Tested Nurse Aide (STNA) #419 standing next to Resident #27 while feeding her bites of oatmeal. Interview at that time with STNA #419 confirmed she was standing over Resident #27 while feeding her. Review of the facility policy titled Assistance With Meals, revised July 2017, revealed residents who cannot feed themselves will be fed with attention to dignity for example: Not standing over residents while assisting them with meals. Interview on 04/21/22 at 11:18 A.M. with the Director of Nursing revealed staff should be seated while providing dining assistance.
Page 1 of 25
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to inform in advance of the risks and benefits of a new treatment order and the option to choose an alternative order of treatment for one (#40) resident out of 15 residents sampled. The facility census was 40.
Residents Affected - Few
Findings include: Review of Resident #40's medical record identified admission to the facility occurred on 01/25/22. Diagnoses included end stage renal disease, anemia, diabetes and peritonitis. Resident #40 discharged on 02/19/22. Review of the admission assessment dated [DATE] revealed Resident #40 was alert and oriented and and independent with decisions. Resident #40 was independent with eating. Review of progress notes on 01/26/22 revealed Resident #40 was upset over his diet order and stated he was not going to be able to tolerate thickened liquids. Review of progress notes on 01/27/22 revealed Resident #40 requested and was denied ice for a dry throat. The notes revealed the dietician assessed Resident #40 on 01/26/22 and clarified the diet order of mechanical soft, nectar thick liquids. Resident #40 was documented in the progress notes as stating Bullshit, ice is the only thing that helps my dry throat. Review of progress notes dated 01/28/22 revealed Resident #40 requested regular water. The notes revealed the resident was informed until therapy changed the diet order they had to go by physician order for nectar thick liquids. Resident #40 became angry stating Go find out now, I'm sick of this shit. Review of speech therapy (ST) notes dated 01/28/22 revealed Resident #40 had a swallowing evaluation and a modified barium swallow at the hospital which showed oropharyngeal phase dysphagia. The ST wrote an order for regular water only between meals and a soft texture diet with nectar consistency fluids. Interview with the Director of Nursing on 04/21/22 at 10:19 A.M. confirmed there was no evidence the facility provided Resident #40 the risk and benefits of the diet order and or allowed Resident #40 to choose his treatment.
365885
Page 2 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0561
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Based on medical record reviews, resident interviews, staff interviews, observations, and review of the facility policy, the facility failed to ensure resident food preferences were served during meals. This affected two (#12 and #25) of three residents reviewed for choices. The facility census was 40.
Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/08/22. Diagnoses included end stage renal disease, type 2 diabetes mellitus, vascular dementia with behavioral disturbance, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 02/23/22, revealed Resident #12 had intact cognition. Review of the care plan initiated 02/10/22 for Resident #12 revealed he had a potential nutritional problem related to type 2 diabetes mellitus and end stage renal disease requiring hemodialysis. Interventions added on 04/06/22 included double portions at all meals. Review of a progress note dated 04/06/22 revealed Resident #12 requested double portions at all meals. Review of the physician orders for Resident #12 revealed an order dated 04/07/22 for double portions with meals. Observation on 04/20/22 at 12:54 P.M. revealed Resident #12 did not have double portions on his meal tray. Interview at the time of the observation with State Tested Nurse Aide (STNA) #419 confirmed Resident #12 received single portions. Review of the meal ticket for Resident #12 revealed no request for double portions. Observation on 04/21/22 at 8:40 A.M. revealed Resident #12 did not have double portions on his meal tray. Interview at the time of the observation with STNA #465 revealed Resident #12 received single portions of menu items on his breakfast tray. Interview on 04/21/22 at 10:06 A.M., Assistant Director of Nursing (ADON) #414 confirmed Resident #12 had a diet order for double portions. Further interview and observation of the meal ticket for Resident #12 confirmed his meal ticket did not include double portions. 2. Review of the medical record for Resident #25 revealed an admission date of 04/16/21. Diagnoses included chronic obstructive pulmonary disease, type 2 diabetes mellitus, oropharyngeal dysphagia, and anxiety disorder. Review of the MDS assessment, dated 03/22/22, revealed Resident #25 had intact cognition. Observation on 04/19/22 at 9:07 A.M. revealed Resident #25 had biscuits and gravy on her breakfast tray. Interview at that time with Resident #25 revealed she did not like biscuits and gravy, and had
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Page 3 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0561
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
received biscuits and gravy on her breakfast tray. Further observation revealed the meal ticket identified Resident #25 disliked biscuits and gravy on her tray. Interview on 04/19/22 at 9:32 A.M. with STNA #437 confirmed Resident #25 received biscuits and gravy on her breakfast tray. STNA #437 confirmed the meal ticket stated the resident had a dislike of biscuits and gravy. Review of the facility policy titled Resident Food Preferences, revised July 2017, revealed resident food preferences would be identified and included in the care plan.
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Page 4 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0636
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed within 14 days of admission for one (#238) our of 15 residents sampled. The facility census was 40.
Findings include: Review of Resident #238's medical record revealed an admission date of 04/07/22. Diagnosis included diabetes mellitus, obesity, seizures, and homicidal ideations. The resident was admitted on Hospice care due to congestive heart failure. As of 04/21/22 Resident #238 did not have a completed MDS assessment. Interview with Licensed Practical Nurse #430 on 04/21/22 at 9:02 A.M. verified the facility failed to complete a MDS assessment for Resident #238.
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Page 5 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0657
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Based on medical record review, resident interview, and staff interviews, the facility failed complete care conferences and provide the opportunity to participate in care planning meetings to make decisions about care for one (#5) out of 15 residents sampled. The facility census was 40.
Findings include: Review of Resident #5's medical record revealed admission to the facility occurred on 02/07/20. Diagnoses included stroke, high blood pressure, dysphasia, and COVID-19. Review of the Minimum Data Set (MDS) assessment, dated 01/10/22, revealed Resident #5 was cognitively intact. The medical record revealed the most recent care plan meeting for Resident #5 occurred on 10/29/21. No additional care plan meetings have occurred since 10/29/21. Interview on 04/18/22 at 7:47 P.M., Resident #5 revealed she has no had a care conference in a long time and she would like to discuss therapy options with the facility. Interview on 04/21/22 at 7:43 A.M., the Assistant Director of Nursing (ADON) confirmed there was no evidence the facility has conducted a care plan meeting for Resident #5 since 10/29/21. The ADON confirmed these should be conducted every three months. Interview on 04/21/22 at 9:02 A.M., Licensed Practical Nurse (LPN) #470 confirmed the facility does not currently have a social worker, which is whom should be scheduling care conference meetings for the residents.
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Page 6 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure showers were provided at a frequency to maintain a clean hygienic appearance for one (#5) of two residents reviewed for activities of daily living. The facility census was 40.
Residents Affected - Few
Findings include: Review of Resident #5's medical record revealed admission to the facility occurred on 02/07/20. Diagnoses included stroke, high blood pressure and seizures. Review of the Minimum Data Set assessment, dated 01/10/22, revealed Resident #5 was cognitively intact and dependant on staff for bathing. Observation and interview with Resident #5 on 04/18/22 at 7:43 P.M. Resident #5's hair was observed to be greasy and somewhat matted together. Resident #5 stated she was not even sure when the last time she received a shower and or her hair was washed. Review of the facility shower schedules revealed Resident #5 should be showered on Wednesdays and Saturdays, on the night shift. Review of the facility shower sheets revealed Resident #5's had one shower sheet completed for 04/06/22 with no other showers provided until two weeks later on 04/20/22. Observation of Resident #5 on 04/21/22 at 7:49 A.M. revealed Resident #5's hair was clean and unmatted. Resident #5 stated she finally got a shower and her hair washed and she felt so much better. Interview on 04/21/22 at 7:43 A.M. the Director of Nursing (DON) confirmed there was no evidence Resident #5 had a shower and/or her hair washed from 04/06/22 to 04/20/22. The interview confirmed Resident #5 should be receiving showers at least twice a week.
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Page 7 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to complete preventive wound care per physician orders for one (#26) of two residents reviewed for pressure ulcers. The facility identified three residents receiving wound care and 35 residents with preventative skin care. The facility census was 40.
Residents Affected - Few
Findings include: Review of Resident #26's medical record revealed an admission date of 10/08/21. Diagnoses included seizures, chronic obstructive pulmonary disease, metabolic encephalopathy, cerebral vascular accident and fibromyalgia. Review of Resident #26's Minimum Data Set (MDS) assessment, dated 03/23/22, revealed the resident had intact cognitive function. She required limited assistance for bed mobility and was dependent on staff for transfers. Review of Resident #26's most recent care plan revealed she had a potential and actual impairment of skin integrity related to fragile skin, immobility, incontinence, and poor nutritional intake. Record review revealed Resident #26 had a healed pressure sore to the right hip and required protective foam to be applied daily. Review of Resident #26's medical record revealed a physician's order dated 03/23/22 to cover the right hip with bordered foam every day. Review of Resident #26's treatment administration record (TAR), dated April 2022, revealed the treatment to Resident #26's right his was not completed on 04/01/22, 04/02/22, 04/03/22, 04/05/22, 04/06/22, 04/07/22, 04/13/22, and 04/18/22. Interview with Resident #26 on 04/18/22 at 11:22 A.M. revealed she had an order for wound care every day, but it was not completed timely. She was afraid her healed pressure ulcer would return if the staff did not follow the physician's order. Interview with the Director of Nursing on 04/21/22 at 09:43 A.M. verified the nurses failed to complete, or document wound care was completed on 04/01/22, 04/02/22, 04/03/22, 04/05/22, 04/06/22, 04/07/22, 04/13/22, and 04/18/22. Review of the facility policy titled Wound Care, dated 11/2020, revealed to verify a physician's order and complete wound care to promote healing.
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Page 8 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0688
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to apply a hand splint as ordered for one (#23) out of two residents reviewed for positioning. The facilty had seven residents with contractures. The facility census was 40.
Findings include: Resident #23 was admitted to the facility on [DATE]. Diagnoses included hemiplegia affecting left side, diabetes mellitus, neuralgia and neuritis, muscle weakness, and major depressive disorder. Review of the physician order, dated 03/04/21, revealed an order for left resting hand splint to be applied with A.M. care and off with P.M. care as tolerated. Splint to be worn for up to 8 hours daily. Observations on 04/19/22 at 9:59 A.M., 12:40 P.M. and again at 4:19 P.M. revealed no splint to Resident #23's left hand. Observations on 04/20/22 at 7:45 A.M. revealed Resident #23 was up in the wheelchair in the dining room. Resident #23 did not have the left hand splint in place. Interview on 04/20/22 at 07:47 AM with the Executive Director and Assistant Director of Nursing #414 verified Resident #23 was to have the left splint applied in the morning with A.M. care. A staff member then retrieved Resident #23's left hand splint from the bin on top of the night stand in her room and applied it to Resident #23's hand. Observations on 04/21/22 at 7:17 A.M. revealed Resident #23 was in the dining room without the left hand splint in place. Resident #23's left hand was observed with the fingers curled down. Additional observation at 8:39 A.M. revealed the absent left hand splint. Resident #23's left hand was observed to be in a ball with the thumb tucked inside the fingers. Interview on 04/21/22 at 8:35 AM with State Tested Nurse Aide (STNA) #416 revealed Resident #23 was to wear a splint to the left hand. STNA #416 stated the splint should be applied in the morning and then off at night.
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Page 9 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide a physician ordered nutritional supplements and failed to provide a physician prescribed therapeutic renal diet. This affected two (#12 and #27) out of five residents reviewed for nutrition. The facility identified four residents who were on nutritional supplements. The census was 40.
Residents Affected - Few
Findings include: 1. Review of Resident #27's medical record revealed an admission date of 09/13/19. Diagnoses included cerebral vascular accident (CVA), dysphagia, hemiplegia, diabetes mellitus, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 03/28/22, revealed Resident #27 had a low cognitive function. The resident required supervision and set up assistance with eating. Review of Resident #27's current care plan revealed she had nutritional problems related to CVA and dysphasia. The care plan showed fluctuating weight changes over the past year. Review of Resident #27's weight record revealed on 09/09/21 the resident weighed 162 pounds. On 12/21/21 the resident weighed 157 pounds. On 01/13/22 the resident's weight was 143.2 pounds, for a 13.8 pound loss equivalent to 8/7% in one month. Review of Resident #27's medical record revealed a physician's order dated 02/11/22 for a sugar free health shake with lunch and dinner for nutrition. Review of Resident #27's dietician note dated 02/16/22 revealed the resident had a weight of 131.8 pounds and was in a steady decline in body weight. She had had a steady decline in body weight despite appropriate nutritional supplements. The physician was notified. Review of Resident #27's weight on 02/21/22 revealed the resident weighed 144 pounds. Review of Resident #27's dietician note dated 03/02/22 revealed resident was down 13% in weight in the last six months. Review of Resident #27's weight on 03/02/22 revealed the resident weighed 140.6 pounds. Observation of lunch service on 04/20/22 at 12:14 P.M. revealed Resident #27 was in the dining room with no nutritional supplement was provided. Observation of lunch service on 04/21/22 at 11:16 A.M. revealed Resident #27 was in the dining room with no nutritional supplement was provided. Interview with [NAME] #403 on 04/21/22 at 12:10 P.M. revealed the dietary staff failed to provide Resident #27 ' s nutritional supplement with meals as ordered. Interview with the Registered Dietician (RD) on 04/21/22 at 3:22 P.M. revealed Resident #27 did
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Page 10 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0692
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
require nutritional supplements. She stated she checked the supply closet and there were plenty of supplemental drinks available. 2. Review of the medical record for Resident #12 revealed an admission date of 02/08/22. Medical diagnoses included end stage renal disease (ESRD), type 2 diabetes mellitus, vascular dementia with behavioral disturbance, and hypertension. Review of the MDS assessment, dated 02/23/22, revealed Resident #12 had intact cognition,and was independent with no setup for eating. Review of the care plan initiated 02/10/22 for Resident #12 revealed he required dialysis three times weekly related to ESRD. Interventions included a CCD/liberal renal diet as ordered. Review of the Nutritional Comprehensive assessment dated [DATE] revealed the dietitian recommended yogurt with all meals. Review of the orders for Resident #12 revealed an order dated 03/03/22 for yogurt three times daily with meals. An order dated 03/10/22 was received for a consistent carbohydrate diet (CCD), renal diet, no oranges, no orange juice, no tomato, potato or banana for nutrition. An order dated 04/19/22 for Boost Glucose Control (BGC) nutritional supplement three times daily for supplement at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Review of the dietary progress note, dated 04/20/22, revealed Resident #12 was underweight and had orders to receive a CCD, renal diet, BGC supplement three times daily, and yogurt three times daily with meals. Review of the meal ticket for Resident #12 on 04/20/22 at 12:54 P.M. and on 04/21/22 at 10:06 A.M. revealed no indication he should receive a CCD, renal diet with dietary restrictions. Observation on 04/20/22 at 12:54 P.M. revealed Resident #12 did not have yogurt with his meal. Interview at the this time with State Tested Nurse Aide (STNA) #419 confirmed Resident #12 did not receive yogurt. Observation on 04/21/22 at 8:40 A.M. revealed Resident #12 received orange juice with his meal and did not receive a yogurt. Interview at this time with STNA #465 verified Resident #12 received orange juice and did not receive yogurt on his meal tray. Additional observation on 04/21/22 at 9:18 A.M. revealed Resident #12 did not received the BGC supplement. Interview at this time with Resident #12 revealed he did not receive a BGC supplement with his breakfast tray. Review of the medication administration record on 04/21/22 at 9:20 A.M. revealed Resident #12 received a BGC supplement. Interview at this time with Licensed Practical Nurse (LPN) #446 confirmed she documented Resident #12 received a BGC supplement though she had not given him a BGC supplement. LPN #446 stated she would provide it to him upon his request. Interview on 04/21/22 at 10:06 A.M. with the Assistant Director of Nursing (ADON) #414 confirmed Resident #12 had a diet orders for CCD, renal diet, with dietary restrictions; yogurt with each meal; and a BGC supplement at 8:00 A.M., 12:00 P.M. and 5:00 P.M ADON #414 confirmed Resident #12's meal
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Page 11 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0692
ticket did not indicate he would receive a CCD, renal diet with dietary restrictions.
Level of Harm - Minimal harm or potential for actual harm
Review of the facility policy titled Therapeutic Diets, dated 10/2017, revealed Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.
Residents Affected - Few
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Page 12 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review the dialysis correspondence notebook, and review of the policy, the facility failed to ensure communication was received from the dialysis clinic after dialysis treatment and failed to check for a bruit and thrill per physician order. This affected two (#12 and #11) of two residents reviewed for dialysis. The facility census was 40.
Residents Affected - Few
Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/08/22. Medical diagnoses included end stage renal disease, type 2 diabetes mellitus, vascular dementia with behavioral disturbance, and orthostatic hypotension. Review of the physician orders dated 04/19/22 revealed Resident #12 had hemodialysis on Monday, Wednesday, and Friday. Review of the dialysis correspondence notebook for Resident #12 revealed the facility received no documentation from the dialysis clinic upon return of Resident #12 from the treatment. Interview on 04/20/22 at approximately 12:00 P.M. confirmed the dialysis clinic did not send reports for Resident #12 after his treatment. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hypertension, encephalopathy, anemia, and dementia. Review of the physician order dated 02/02/22 revealed an order for left lower arm to be assessed for thrill and bruit every shift. Review of the medical records revealed no evidence of the thrill and bruit being assessed on the day shift on 04/02/22, 04/04/22, 04/05/22, 04/07/22, 04/08/22, 04/10/22, 04/12/22, 04/16/22 and 04/18/22 or on the evening shift on 04/06/22 and 04/12/22. Interview with Resident #11 on 04/20/22 at 8:11 A.M. revealed staff are not checking fistula for thrill and bruit. Interview with the Director of Nursing on 04/21/22 at 3:25 P.M. verified the missing bruit and thrill assessments on 04/02/22, 04/04/22, 04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/10/22, 04/12/22, 04/16/22 and 04/18/22. Review of policy titled Hemodialysis Access Care, revised 2010, revealed patency of site should be checked at regular intervals. Palpate the site to feel the thrill or use stethoscope to hear the bruit of blood flow through the access.
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Page 13 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0773
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Based on medical record reviews and staff interviews, the facility failed to obtain physician ordered laboratory (lab) tests for two (#3 and #23) of seven residents sampled for medication review. The facility census 40.
Findings include: 1. Review of Resident #3's medical record revealed admission to the facility occurred on 09/01/20. Diagnoses included atrial flutter, chronic obstructive pulmonary disease and congestive heart failure. Review of the current physician orders revealed Resident #3 was to have a liver function and thyroid stimulating hormone (TSH) lab test completed every six months. Review of Resident #3 lab tests revealed a liver function test and a TSH level were obtained on 08/19/21. The record identified no testing was completed in February 2022 as ordered. Interview with the Director of Nursing (DON) on 04/21/22 at 12:11 P.M. confirmed the facility did not complete the TSH and liver function testing for Resident #3 as ordered. 2. Review of Resident #23's medical record identified admission to the facility occurred on 04/20/16. Diagnoses included diabetes, stroke, and high blood pressure. Review of the current physician orders revealed a comprehensive metabolic panel (CMP), lipids and hemoglobin A1C were to be completed every six months. Review of Resident #23's lab results revealed on 07/22/21 the CMP, hemoglobin A1C, and lipids were obtained. he records lacked evidence of of the laboratory testing being completed in January 2022. Interview with the DON on 04/21/22 at 12:11 P.M. confirmed Resident #23's laboratory testing was not completed in January 2022 as ordered.
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Page 14 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm or potential for actual harm
Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received regular dental services. This affected one (#35) of two residents reviewed for dental services. The facility census was 40.
Residents Affected - Few
Findings include: Review of Resident #35's medical record revealed an admission date of 07/12/21. Diagnoses included type II diabetes, dysphagia, major depressive disorder, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 03/25/22, revealed Resident #35 was cognitively intact. Resident #35 had no mouth or facial pain or discomfort with chewing and had no obvious cavities or broken teeth at the time of the review. Review of Resident #35's care plan, revised 04/19/22, revealed supports and interventions for oral/dental health problems. Interventions included coordinating arrangements for dental care and transportation as needed, monitor for any signs or symptoms of oral problems needing attention, and to encourage to brush his teeth at least in the morning and at night. Review of Resident #35's Health Care Services Consent form dated 07/22/21 revealed Resident #35 accepted dental service provided by the facility. Review of Resident #35's medical record revealed there was no evidence Resident #35 had been seen by a dentist. Observation on 04/18/22 at 9:10 P.M. revealed Resident #35 had brown discolored teeth and missing teeth. Interview on 04/18/22 at 9:14 P.M., Resident #35 stated he saw a physician but had not seen a dentist. Interview on 04/21/22 at 12:49 P.M. with the Director of Nursing (DON) verified there was no record of Resident #35 being seen by a dentist. Review of the facility policy titled Dental Services, dated December 2016 revealed routine dental services were to be provided to residents.
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Page 15 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0801
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Based on observations and staff interview, the facility failed to have a director of food and nutrition services to provide oversight for the sanitation of the kitchen and the serving of physician ordered diets. This affected all 40 residents who reside in the facility.
Findings include: Observations from 04/18/22 through 04/21/22 revealed no dietary staff member who was identified as in charge of kitchen. Observations and interviews between 04/19/22 and 04/21/22 revealed the facility failed to store food appropriately; failed to prepare food appropriately; failed to maintain a clean, sanitary kitchen; failed to serve food that was palatable, failed to provide adaptive equipment for meals, and failed to serve meals according to physician orders. Interview on 04/21/22 at approximately 3:00 P.M. with the Administrator revealed the facility has had no Dietary Manager since 02/08/22. Interview with the Registered Dietician (RD) on 04/21/22 at 3:22 P.M. revealed she was aware there was an issue with the kitchen staff not following diet orders and she thought the Administrator was going to send the new cook for training to learn how to run the kitchen.
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Page 16 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm or potential for actual harm
Based on resident interview, observation of a meal test tray, and staff interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability for 13 (#4, #5, #6, #11, #12, #21, #24, #26, #27 and #33) residents with food complaints. The census was 40.
Residents Affected - Some
Findings include: Interviews were completed with Resident #4, #5, #6, #11, #12, #21, #24, #26, #27 and Resident #33 at various times on 04/18/22 regarding meals services. All 13 residents had concerns regarding meals being cold, The residents identified this has been an on-going concern for quite a while. Observation on 04/19/22 at 12:37 P.M. revealed the requested test tray was placed on top of the food delivery cart and exited the kitchen. All resident meals were placed inside the delivery cart. Residents trays were delivered by staff on 04/19/22 between 12:39 P.M. and approximately 12:53 P.M. The test tray was removed from cart on 04/19/22 at 12:55 P.M. Test tray temperatures on 04/19/22 at approximately 12:57 P.M. revealed the diced potatoes were 90 degrees Fahrenheit, some pieces were charred and the potatoes were unpalatably cool. Interview on 04/19/22 at approximately 12:58 P.M. with Business Office Manager (BOM) #402 confirmed the temperature reading of the food from the thermometer and confirmed some pieces of the diced potatoes were charred. BOM #402 declined to taste the food.
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0805
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, observation of meal tickets, policy review and staff interview, the facility failed to provide the correct physician ordered diet consistency for three(#4, #27, #338) out of five residents reviewed for nutrition. The facility identified four residents who were ordered mechanical soft diets. The census was 40.
Findings include: 1. Review of Resident #27's medical record revealed an admission date of 09/13/19. Diagnoses included cerebral vascular accident (CVA), dysphagia, hemiplegia, diabetes mellitus, and congestive heart failure. Review of Resident #27's Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the resident had a low cognitive function. The resident required supervision and set up assistance with eating. Review of Resident #27's most recent care plan revealed she had nutritional problems related to CVA and dysphagia. The resident needed a therapeutic diet and mechanical soft diet texture due to aspiration precautions. Review of Resident #27's dietician note dated 02/16/22 revealed the diet ordered was a carbohydrate controlled diet with mechanical soft texture. Observation of lunch service on 04/21/22 at 11:16 A.M. revealed Resident #27 continued to be served a regular diet. Interview with [NAME] #403 on 04/21/22 at 12:10 P.M. verified Resident #27 was ordered a mechanical soft texture diet. Interview with the Registered Dietician (RD) on 04/21/22 at 3:22 P.M. revealed she was aware that there was an issue with the kitchen staff not following diet orders and she thought the Administrator was going to send the new cook to learn how to run the kitchen. Review of the facility policy titled Therapeutic Diets, dated 10/2017, revealed Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If a mechanically altered diet is ordered, the provider will specify the texture modification. 2. Review of Resident #338's medical record revealed an admission date of 04/06/22. Diagnosis included homicidal ideations, atherosclerotic heart disease, and cardiac pacemaker. Review of Resident #338's MDS assessment, dated 04/13/22, revealed the resident was independent of eating and required set up help only. Review of Resident #338's most recent care plan revealed the resident had a nutritional problem related to dementia with behaviors need for therapeutic mechanical soft diet and to have all food chopped. Interventions included to provide and serve the diet as ordered.
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0805
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Review of Resident #338's medical record revealed a physician order dated 04/06/22 for a no added salt, mechanical soft texture diet. All textured foods were to be chopped. Observation of meal service on 04/20/22 at 12:10 P.M. revealed Resident #338 was served a small whole pizza for lunch. The resident was unable to eat the pizza and asked staff for assistance. State Tested Nurse Aide (STNA) #419 attempted to cut up the pizza with a knife and fork. The pizza appeared to be difficult to cut due to being hard. Interview with STNA #419 on 04/20/22 at 12:14 P.M. verified Resident #338 pizza was not chopped. Review of the facility provided list of residents requiring a mechanical soft diet revealed Resident #338 was omitted from the list. 3. Review of the medical record revealed Resident #4 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus and hypertension. Review of Resident #4's physician orders revealed an order dated 04/15/22 for a regular diet. Interview on 04/19/22 at 9:29 P.M., Resident #4 stated he was not receiving the right meal. Stating he continues to receive mechanical soft foods with ground meat when his diet was changed to a regular diet a couple of days ago Observation on 04/19/22 at 12:43 P.M. revealed revealed Resident #4 was served ground pork for lunch. Observation at this time of the meal ticket revealed it identified Resident #4 to require a mechanical soft diet with ground meat. Interview on 04/19/22 at 12:43 P.M., [NAME] #404 verified Resident #4 was served a mechanical soft diet with ground meat. Interview with the Director of Nursing (DON) on 04/20/22 at 1:35 P.M. verified Resident #4 was not receiving the correct diet. The DON verified Resident #4's diet was changed on 04/15/22 to a regular consistency.
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm or potential for actual harm
Based on medical record review, observation, policy review and staff interview, the facility failed to provide adaptive devices at meals for one (#27) of five residents reviewed for nutrition. The facility identified no residents requiring assistive meal devices. The census was 40.
Residents Affected - Few
Findings include: Review of Resident #27's medical record revealed an admission date of 09/13/19. Diagnoses included cerebral vascular accident (CVA), dysphasia, hemiplegia, diabetes mellitus, and congestive heart failure. Review of Resident #27's Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the resident required supervision and set up assistance with eating. Review of Resident #27's most recent care plan revealed she had nutritional problems related to CVA and dysphasia. Interventions added on 01/21/22 included the use of a plate guard and a non-skid mat. Observation of breakfast service on 04/20/22 at 8:14 A.M. revealed Resident #27 was in the dining room. The resident failed to be provided a non-skid mat and dish with plate guard. Observation of lunch service on 04/20/22 at 12:14 P.M. revealed Resident #27 was in the dining room and served her meal. No adaptive equipment was provided. Interview with State Tested Nurse Aide (STNA) #419 on 04/20/22 at 12:04 P.M. verified no non- skid mat or plate guard was provided to Resident #27. Observation of lunch service on 04/21/22 at 11:16 A.M. revealed Resident #27 was served her meal but was not provided with the non-skid mat and plate guard. Interview with [NAME] #403 on 04/21/22 at 12:10 P.M. verified Resident #27 was supposed to have an anti skid mat but the facility failed to have any in stock. The facility also failed to had a plate guard available so one could not be provided to the resident. [NAME] #403 verified the resident's meal ticket was marked as requiring a non-skid mat which was failed to be provided. Interview with the Registered Dietician (RD) on 04/21/22 at 3:22 P.M. verified Resident #27 did require a non-skid mat and plate guard with all meals. The RD revealed she was aware that there was an issue with the kitchen staff not following diet orders. Review of the facility policy titled Assistance With Meals, dated 07/2017, revealed adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may included devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups.
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0812
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation, staff interview, review of dishwasher sanitation logs, and review of the facility policies, the facility failed to store food in a safe manner, failed to maintain a clean and sanitary kitchen area, and failed to prepare and serve food in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 40.
Findings include: 1. Observations during tour of the facility kitchen on 04/18/22 between 6:35 P.M. and 7:15 P.M. revealed the refrigerator had chopped cabbage and diced carrots dated 04/12/22, unsealed and undated shredded cheddar cheese, unsealed and undated mozzarella cheese, an undated bowl of potato salad, and approximately 20 single-serving green salads uncovered and undated. The freezer had undated and unsealed meatballs, vegetable egg rolls, chicken patties, and biscuits. The dry storage area had opened, undated raisins. The wire rack of the toaster upon which bread was placed before starting the conveyor belt was coated with debris. Crumbs and debris were on the counter around the toaster, there was a dried substance on the steam table, and floating items in the deep fryer. Interview with the [NAME] #404 on 04/18/22 at approximately 7:10 P.M. confirmed confirmed the items in the refrigerator should have been dated and sealed, and the cabbage and carrots should have been discarded. [NAME] #404 also confirmed the dirty toaster, debris on the counter, and dried gravy on the steam table. [NAME] #404 stated the staff had completed the cleaning for the day and was planning to leave the kitchen when the tour of the kitchen began. Review of the log to monitor the chemical dishwasher temperatures and chlorine concentration on 04/20/22 at 4:26 P.M. revealed it was dated January 2022 and was blank. Concurrent interview with Dietary Aide #411 confirmed the log was blank. Dietary Aide #411 and Dietary Aide #407 stated they did not know how to test the chlorine concentration of the dishwasher. Observation on 04/20/22 at 4:40 P.M. revealed a half-gallon of 2% milk dated 04/11/22 in the snack refrigerator at the nurses' station. Concurrent interview with State Tested Nurse Aide (STNA) #426 confirmed the expired milk was in the snack refrigerator. Interview on 04/20/22 at 5:05 P.M. with the Administrator revealed no dishwasher logs were available for February, March, and April 2022, and confirmed the dish machine logs were not completed in January 2022. Interview on 04/21/22 at 1:33 P.M. with the [NAME] #404 revealed the facility does not use a cleaning schedule. 2. Observation on 04/19/22 at 11:20 A.M. revealed [NAME] #404 preparing for the lunch meal service. [NAME] #404 was observed taking the temperature of the pork tenderloin. He used a dry paper towel to wipe the thermometer and placed the un-sanitized thermometer into the broccoli. [NAME] #404 wiped the thermometer with the same dry paper towel and placed it in the roasted potatoes. Observation on 04/19/22 at 11:50 A.M. revealed [NAME] #404 took the temperature of the pureed pork loin, wiped the thermometer with a dry white paper towel, and placed the thermometer in the pureed broccoli.
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Page 21 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0812
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Interview on 04/19/22 at 11:53 A.M. with [NAME] #404 verified there were disinfectant wipes available for cleaning the thermometer between food items but he had not used them. Review of the facility policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, revealed all employees who handle, prepare or serve food will be trained in the practices of safe food handling. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents Review of the undated facility policy titled Food Preparation and Service revealed leftovers will be labeled and dated. Leftovers will not be held longer than 48 hours. Food will be served at acceptable temperatures. 3. Observation on 04/19/22 at 11:53 A.M. of the kitchen found [NAME] #404 preparing dinner plates with pork, broccoli, potatoes, and gravy for dining room service with gloved hands. [NAME] #404 left the kitchen carrying two prepared plates into the dining room, returning at through the closed kitchen door without changing her gloves. At 12:03 P.M. [NAME] #404 returned to the steam table and began to prep six additional plates for service. At 12:04 P.M. [NAME] #404 carried two plates to the dining room and returned to the kitchen at 12:06 P.M. holding the door open with his gloved right hand as he spoke with Resident #16. At 12:08 A.M. [NAME] #404, without changing his gloves, cut two pieces of pork using a knife and fork on a cutting board. [NAME] #404, used his gloved hands to pick each piece of pork up, placing the pork back into the steam pan on the steam table. Interview with [NAME] #404 on 04/19/22 at 1:21 P.M. verified he did not change gloves or wash hands upon returning the kitchen to prepare more plates for service after serving meals in the dining room. [NAME] #404 verified he touched the door handle and the door to the kitchen when entering and then touched the pork.
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Page 22 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0842
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate medical record. This affected one (#12) of 15 residents reviewed. The facility census was 40.
Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/08/22. Medical diagnoses included end stage renal disease, type 2 diabetes mellitus, vascular dementia with behavioral disturbance, and orthostatic hypotension. Review of the hospital records for Resident #12 revealed he was hospitalized from [DATE] to 02/21/22. Review of the medication administration record for Resident #12 for February 2022 revealed staff documented vital signs on 02/18/22 during day shift, 02/19/22 during night shift, and 02/20/22 during day shift. Interview on 04/20/22 at 1:34 PM with the Director of Nursing confirmed Resident #12 was hospitalized and not in the facility from 02/15/22 to 02/21/22 and staff charted vital signs on 02/18/22, 02/19/22, and 02/20/22. Review of the policy titled Charting and Documentation, revised July 2017, revealed documentation in the medical record would be accurate.
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365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0867
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Based on staff interview and review of facility documents, the facility failed to have an effective quality assurance program to address repeated concerns identified during three consecutive annual surveys. This affected all residents in the facility. The facility census was 40.
Findings include: Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) report dated 02/18/22 revealed the facility received a deficiency for food procurement, food storage, food preparation during the annual surveys completed on 04/19/18 and 05/30/19. Interviews and observations between 04/19/22 and 04/21/22 revealed the facility failed to store food appropriately, failed to prepare food appropriately, and failed to maintain a clean, sanitary kitchen. Interview on 04/21/22 at 2:14 P.M. with the Administrator revealed the facility could provide no documentation the Quality and Performance Improvement (QAPI) committee met in 2021 or 2022. Interview on 04/21/22 at approximately 3:00 P.M. with the Administrator revealed the facility had no Dietary Manager since 02/08/22.
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Page 24 of 25
365885
04/25/2022
Concord Care and Rehabilitation Center
620 W Strub Rd Sandusky, OH 44870
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm or potential for actual harm
Based on staff interview and review of facility documents, the facility failed to ensure a quality assessment and assurance committee met at least quarterly. This affected all residents in the facility. The facility census was 40.
Residents Affected - Many
Findings include: Review of the facility documents revealed no Quality and Performance Improvement (QAPI) committee sign-in sheets or minutes were available for 2021 and 2022. Interview on 04/21/22 at 2:14 P.M. with the Administrator revealed the facility could provide no documentation the Quality and Performance Improvement (QAPI) committee met in 2021 or 2022.
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Back to topCitations
20 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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
FAQ · About this visit
Common questions about this visit
What happened during the April 25, 2022 survey of CONCORD CARE AND REHABILITATION CENTER?
This was a inspection survey of CONCORD CARE AND REHABILITATION CENTER on April 25, 2022. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CONCORD CARE AND REHABILITATION CENTER on April 25, 2022?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.