Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to effectively implement their Abuse policy and procedure for
Resident #141 and Resident #142 related to the completion of thorough and complete investigations. This
affected two residents (Resident #141 and #142) and had the potential to affect all 43 residents residing in
the facility.
Residents Affected - Many
Findings include:
1. Review of a facility self reported incident (SRI), dated 02/06/19 revealed on 02/06/19 at 4:40 P.M.,
Resident #141 reported an allegation of abuse to Registered Nurse (RN) #206. The resident alleged State
Tested Nursing Assistant (STNA) #210 was rough with her during care, yanking at her pants while pulling
her pants up and digging her fingernails into her legs. RN #206 immediately reported the allegation, and
STNA #210 was removed from the facility.
Review of the facility's investigation of the SRI dated 02/06/19 revealed there were witness statements from
the alleged perpetrator (STNA #210), RN #206, STNA #207, and STNA #208. The investigation included
only one resident interview, Resident #141. There was no evidence of interviews with any other resident
STNA #210 cared for the afternoon of 02/06/19.
During an interview on 05/29/19 at 12:11 P.M., the administrator verified the facility obtained no other
resident interviews during the investigation of Resident #141's allegation of abuse on 02/06/19.
Review of the facility's Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy,
revised November 2016 revealed when an incident or suspected incident of abuse was reported, the
administrator or designee would investigate the incident. The investigation would include who was involved,
residents' statements, resident's roommate statement, involved staff and witness statement of events, a
description of the resident's behavior and environment at the time of the incident, injuries present including
a resident assessment, observation of resident and staff behaviors during the investigation, and
environmental considerations.
2. Review of the medical record for Resident #142 revealed the resident was admitted to the facility on
[DATE] with diagnoses including pneumonia, acute respiratory failure, pulmonary disease, macular
degeneration, anxiety, diabetes, bilateral hard of hearing, stroke, low vision with both eyes and glaucoma.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/05/19 revealed Resident #142 was
cognitively intact. The MDS revealed the resident had moderate hearing difficulty requiring the speaker
(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 7
Event ID:
366289
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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 0607
to increase volume and speak distinctly in addition to having highly impaired vision.
Level of Harm - Potential for
minimal harm
Review of a facility Self-Reported Incident dated 01/31/19 revealed on 01/31/19 Resident #142 reported to
the Director of Nursing and Registered Nurse (RN) Supervisor #201, that State Tested Nurse Aide (STNA)
#204 declined to perform personal care and physically harmed him.
Residents Affected - Many
Review of the facility investigation revealed on 01/31/19 STNA #204 reported to licensed practical nurse
(LPN) #200 that Resident #142 was accusing her of being abusive. STNA #204 denied the allegation. LPN
#200 and Registered nurse (RN) supervisor #201 placed STNA #204 on administrative leave during the
investigation. When interviewed by the Director of Nursing (DON), STNA #204 denied the allegations of
physical and emotional abuse and neglect. LPN #200 interviewed Resident #142 and the resident's
spouse/Resident #198. Resident #142 said STNA #204 was mean, pushed him around in bed and pulled
his breathing treatment mask off roughly. Resident #198 stated she heard STNA #204 speaking loudly and
was mean. The investigation further revealed an interview with STNA #203. STNA #203 reported Resident
#142 told her STNA #204 was moving at a pace that was not to his liking, too fast, too loud. The
investigation revealed a statement by RN #201 that indicated Resident #142 reported STNA #204 was
shouting and choked the resident with the breathing treatment tube. Each staff report contained different
allegations with the only consistent allegation of STNA #204 speaking in a loud voice.
Review of the Self-Reported Incident revealed no additional residents or staff were interviewed as part of
the facility investigation to determine if other residents and staff had knowledge of the incident or if other
residents might have been affected.
On 05/29/19 at 9:23 A.M. an interview with the administrator verified other relevant resident or staff
interviews were not completed in regard to the investigation of alleged abuse involving Resident #142.
Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property,
dated November 2016 revealed it was the facility policy to report and investigate suspicion and awareness
of any abuse, neglect or misappropriation of residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 2 of 7
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #141's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses
including right knee pain, muscle weakness, and arthritis. Review of the admission Minimum Data Set
(MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and required supervision
and limited assistance with transfer and toileting.
Residents Affected - Few
Review of an SRI dated 02/06/19 revealed on 02/06/19 at 4:40 P.M., Resident #141 reported an allegation
of abuse to RN #206. The resident alleged STNA #210 was rough with her during care, yanking at her
pants while pulling her pants up and digging her fingernails into her legs. RN #206 immediately reported
the allegation, and STNA #210 was removed from the facility.
Review of the facility's investigation of the SRI dated 02/06/19 revealed there were witness statements from
the alleged perpetrator (STNA #210), RN #206, STNA #207, and STNA #208. The investigation included an
assessment of Resident #141's body for injury and an interview with Resident #141. There was no
evidence of interviews with any other resident STNA #210 cared for the afternoon of 02/06/19.
During an interview on 05/29/19 at 12:11 P.M., the administrator verified the facility obtained no other
resident interviews during the investigation of Resident #141's allegation of abuse on 02/06/19.
Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property,
dated November 2016 revealed it was the facility policy to report and investigate suspicion and awareness
of any abuse, neglect or misappropriation of residents.
Based on record review and interview the facility failed to complete a thorough and comprehensive
investigation following an allegation of physical, emotional abuse and neglect involving Resident #142 and
following an allegation of physical abuse involving Resident #141. This affected two residents (Resident
#142 and Resident #141) of two residents reviewed for abuse.
Findings include:
1. Review of the medical record for Resident #142 revealed the resident was admitted to the facility on
[DATE] with diagnoses including pneumonia, acute respiratory failure, pulmonary disease, macular
degeneration, anxiety, diabetes, bilateral hard of hearing, stroke, low vision with both eyes and glaucoma.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/05/19 revealed Resident #142 was
cognitively intact. The MDS revealed the resident had moderate hearing difficulty requiring the speaker to
increase volume and speak distinctly in addition to having highly impaired vision.
Review of a facility Self-Reported Incident (SRI) dated 01/31/19 revealed on 01/31/19 Resident #142
reported to the Director of Nursing and Registered Nurse (RN) Supervisor #201, that State Tested Nurse
Aide (STNA) #204 declined to perform personal care and physically harmed him.
Review of the facility investigation revealed on 01/31/19 STNA #204 reported to licensed practical nurse
(LPN)#200 that Resident #142 was accusing her of being abusive. STNA #204 denied the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 3 of 7
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
allegation. LPN #200 and Registered nurse (RN) supervisor #201 placed STNA #204 on administrative
leave during the investigation. When interviewed by the Director of Nursing (DON), STNA #204 denied the
allegations of physical and emotional abuse and neglect. LPN #200 interviewed Resident #142 and the
resident's spouse/Resident #198. Resident #142 said STNA #204 was mean, pushed him around in bed
and pulled his breathing treatment mask off roughly. Resident #198 stated she heard STNA #204 speaking
loudly and was mean. The investigation further revealed an interview with STNA #203. STNA #203 reported
Resident #142 told her STNA #204 was moving at a pace that was not to his liking, too fast, too loud. The
investigation revealed a statement by RN #201 that indicated Resident #142 reported STNA #204 was
shouting and choked the resident with the breathing treatment tube. Each staff report contained different
allegations with the only consistent allegation of STNA #204 speaking in a loud voice.
Review of the Self-Reported Incident revealed no additional residents or staff were interviewed as part of
the facility investigation to determine if other residents and staff had knowledge of the incident or if other
residents might have been affected.
On 05/29/19 at 9:23 A.M. an interview with the administrator verified other relevant resident or staff
interviews were not completed in regard to the investigation of alleged abuse involving Resident #142.
Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property,
dated November 2016 revealed it was the facility policy to report and investigate suspicion and awareness
of any abuse, neglect or misappropriation of residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 4 of 7
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of manufacturer's recommendations and interview the facility failed to ensure expired
medications and medications past the use by date were discarded. This affected one resident (Resident
#21) of six residents with eye drops located in the [NAME] Unit medication cart and had the potential to
affect all residents when stock medications located in the intravenous (IV) cart were found expired. The
facility census was 43.
Findings include:
1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with
a diagnosis including glaucoma. The resident had a physician order, dated 01/11/19 for Pilocarpine 4
percent (%) eye drops one drop both eyes four times daily, Timolol maleate 0.5% eye drops one drop two
times daily, and Azopt 1% one drop both eyes three times daily.
On 05/29/19 at 5:42 P.M., an observation of the [NAME] Unit medication cart was completed accompanied
by Registered Nurse (RN) #220. Eye medications found inside the medication cart include:
A 15 milliliter (ml) bottle of Pilocarpine hydrochloride ophthalmic solution 4% belonging to Resident #21.
The bottle was dated as opened on 01/24/19.
A 10 ml bottle of Timolol maleate (Timoptic) 0.5% eye drops belonging to Resident #21. The bottle was
dated as opened on 01/24/19.
A 10 ml bottle of Azopt 1% ophthalmic suspension belonging to Resident #21. The bottle was dated as
opened on 03/17/19.
On 05/29/19 at 5:50 P.M., an interview with RN #220 confirmed the dates the eye drops were opened.
Review of the manufacturer's prescribing information for Pilocarpine hydrochloride, Timolol maleate, and
Azopt ophthalmic solution revealed no indication how long the eye drops were safe after opening.
On 05/29/19 at 6:19 P.M., RN #220 was unable to provide any manufacturers' information to indicate how
long the eye drops could be kept once opened.
Center for Medicaid and Medicare (CMS) guidance indicated eye drops in multi-dose packaging contain
preservatives to ensure the sealed product remains sterile. After opening however, the preservative can
only ensure the drops are safe for the eye for a period of 28 days. Beyond 28 days, using the drops may
cause serious damage to the eye as bacteria may have been introduced.
2. On 05/29/19 at 5:52 P.M., an observation of the facility intravenous (IV) medication cart was completed
accompanied by RN #220. The cart was located in the [NAME] Unit medication room. Antibiotics found
inside the IV medication cart included:
Five vials each containing Cefazolin 1 gram (gm) with expiration date of 01/2019.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 5 of 7
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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 0755
Four vials each containing Ceftazidime 1 gm with expiration date of 04/2019.
Level of Harm - Minimal harm
or potential for actual harm
Two vials each containing Piperacillin/Tazobactam (Zosyn) 3.375 gm with expiration date of 03/2019 and
one vial with expiration date of 03/01/19.
Residents Affected - Many
Two vials each containing Gentamicin 80 milligrams/2 ml with expiration date of 03/2019.
One vial containing Tobramycin 80 milligrams/2 ml with expiration date of 03/2019.
On 05/29/19 at 06:24 P.M., RN #220 confirmed the above antibiotics were expired.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 6 of 7
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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, record review and interview the facility failed to maintain effective infection control practices
during urinary catheter care to prevent the spread of infection. This affected one resident (Resident #146) of
one resident reviewed for urinary catheters.
Residents Affected - Few
Findings include:
Review of Resident #146's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including urinary tract infection and benign prostatic hyperplasia (BPH) with indwelling urinary
catheter. The resident had a physician order, dated 05/17/19 for the antibiotic, Cefdinir 300 milligrams every
12 hours for 10 days for treatment of a urinary tract infection. A physician order dated 05/17/19 indicated
Resident #146 was to have urinary catheter care every shift.
On 05/30/19 beginning at 1:22 P.M., an observation of urinary catheter care was completed. State tested
nursing assistant (STNA) #212 applied gloves and assisted Resident #146 to transfer to the toilet. Using a
soapy, wet washcloth, the STNA cleaned the urinary catheter bag tubing from where it connected to the
catheter down toward the urine collection bag. She then rinsed and dried the tubing. STNA #212 emptied
the urine from the bag into a graduated container then cleaned the outlet port of the bag with alcohol pads.
At this point, the STNA left the room wearing the same gloves she used to clean the tubing and empty
urine from the catheter bag. She returned to Resident #146's room a short time later still wearing gloves.
Resident #146 was still on the toilet and had a bowel movement. The STNA prompted the resident to wipe
himself then she cleaned his buttocks with pre-moistened wipes. STNA #212 using a soapy, wet washcloth
provided urinary catheter care, cleaning around the insertion site at the end of the penis then the catheter
from the insertion site outward. She then rinse and dried the area. With a clean soapy, wet washcloth, the
STNA provided perineal care, cleaning the groin area then the buttocks. After completing perineal care, she
assisted Resident #146 to transfer to his wheelchair. STNA #212 then pushed the wheelchair into the sitting
area in his room and assisted the resident to transfer to his recliner. She repositioned his overbed table next
to the resident then moved the call light on top of the bed. The STNA emptied and rinsed the graduated
container holding the urine and placed the soiled towels and washcloths in a plastic bag. The STNA then
removed the gloves and washed her hands.
The only time STNA #212 was observed removing gloves and washing and/or cleansing hands was after
she completed the entire procedure.
During an interview on 05/30/19 at 1:47 P.M., STNA #212 indicated she changed her gloves after giving
peri care and just now after completing care. She agreed she touched many things with the gloved hands.
STNA #212 verified she did not wash or cleanse her hands between glove changes.
Review of the facility Hand Washing Policy, revised May 2014 revealed handwashing with liquid soap and
water must be performed after the following: three concurrent uses of hand sanitizer, contact with moist
body fluids, after glove removal, and after touching infectious material.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 7 of 7
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Back to topCitations
8 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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 30, 2019 survey of CONCORDIA AT SUMNER?
This was a inspection survey of CONCORDIA AT SUMNER on May 30, 2019. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CONCORDIA AT SUMNER on May 30, 2019?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.