BELLA VISTA, AR - Federal inspectors documented severe medical record deficiencies at Concordia Nursing & Rehab during a May 2025 inspection, finding the facility operating without essential documentation needed for safe resident care.
Critical Leadership Vacancy Creates Documentation Crisis
The most concerning finding centered on the facility operating without a Director of Nursing (DON) for an extended period. During the survey entrance conference on April 21, 2025, the Administrator reported there was no DON on staff, with a corporate Licensed Practical Nurse (LPN) completing Minimum Data Sets remotely.
The Medical Records Nurse told inspectors during an April 22 interview that she had been "working the floor for about 6 months and haven't been able to do medical records." She explained that resident care took priority over documentation, stating "paperwork comes second."
An LPN interviewed on April 22 confirmed that "no care plans had been generated since they didn't have a Director of Nursing." Residents only had basic closet care plans filled out during admission evaluations, typically completed by Medical Records staff who were also working as charge nurses.
Missing Physician Orders Create Safety Risks
The lack of organized medical records extended to critical physician orders. During an April 27 interview, a Registered Nurse explained that "written orders are no longer on the paper chart and nurses don't know where they are or where to find them."
The Medical Director acknowledged the severity of the documentation failures during his April 27 interview. When discussing a specific resident's oxygen orders, he had to leave the room twice to search for the orders in medical records. He stated, "There is a delay of trying to get caught up and it is my fault why notes are not in the chart."
Most alarmingly, the Medical Director admitted he didn't understand how staff could provide care without proper documentation: "I don't know how nurses check orders or where nurses get the orders and information from to provide care to the residents." He characterized the situation as a "system failure" and stated, "I don't know how staff take care of residents if it's not in the paper chart."
Comprehensive Assessment Failures
Federal regulations require nursing homes to conduct comprehensive assessments within 14 days of admission, followed by comprehensive care plans within seven days. These documents guide staff in providing appropriate care and monitoring resident conditions.
Inspectors found multiple residents lacking these critical assessments. Resident #85's medical record contained no Minimum Data Set (MDS) assessment, baseline care plan, comprehensive care plan, or activity notes. Resident #184's record was missing comprehensive care plans, MDS assessments, provider notes, and oxygen orders despite the resident using oxygen and CPAP equipment.
The Assistant Director of Nursing, interviewed by phone on April 29, confirmed that "nobody had assumed those responsibilities" typically handled by the DON, including care plans, fall assessments, and MDSs. She explained that she was working bedside daily while also serving as Infection Preventionist, making it impossible to take on additional DON duties.
Medical Expert Concerns About Documentation Impact
Missing medical records create significant patient safety risks in nursing home settings. Care plans serve as roadmaps for staff, detailing specific interventions needed for each resident's medical conditions, dietary requirements, mobility assistance, and behavioral management strategies.
When physician orders are missing or inaccessible, nurses cannot verify correct medication dosages, treatment frequencies, or special care instructions. This documentation gap forces staff to make clinical decisions without complete information about resident needs and physician directives.
Comprehensive assessments identify changes in resident conditions that require modified care approaches. Without these evaluations, staff may miss early signs of health decline, medication side effects, or need for additional services.
Regulatory Standards for Medical Records
Federal regulations mandate that nursing homes maintain complete, accurate, and readily accessible medical records for all residents. These requirements ensure continuity of care when staff members change shifts or when new employees begin caring for residents.
The Centers for Medicare & Medicaid Services requires specific documentation including physician orders, care plans updated at least quarterly, comprehensive assessments, medication administration records, and treatment records. Each document serves specific functions in coordinating resident care among multiple healthcare team members.
Facilities must designate qualified staff to manage medical records systems and ensure information remains current. The DON position carries specific responsibilities for overseeing care plan development and ensuring nursing staff have access to necessary documentation.
Systemic Failures Beyond Documentation
The inspection revealed additional operational concerns stemming from inadequate facility assessment processes. Concordia failed to conduct thorough self-assessments of staffing capabilities, emergency preparedness, or specialized care services like IV therapy.
Despite providing intravenous therapy services to residents, the facility had no plan for training Licensed Practical Nurses on IV medication administration or tracking outside certifications for specialized procedures. This created additional safety risks for residents requiring complex medical interventions.
The facility's staffing assessment used outdated ratios that had been superseded by state regulations, and administrators never outlined specific staffing needs despite regulatory requirements for quarterly evaluations of resident care demands.
Former Employee Allegations
A former Human Resources Director, interviewed on May 5, 2025, made serious allegations about administrative practices during the inspection period. She claimed to have witnessed the Administrator signing staff names to in-service training records and altering time records to show required nursing coverage that did not actually occur.
The former employee specifically referenced concerns about fabricated documentation, stating she "knew you would know it was fake since it took so long to get it" when discussing treatment administration records for a specific resident.
Infection Control Implications
The documentation crisis affected infection prevention protocols. Staff reported confusion about Enhanced Barrier Precautions and Transmission Based Precautions, with some nurses stating they had not received training on protective equipment requirements.
A former Director of Nursing, interviewed on April 28, admitted uncertainty about infection control procedures, stating "I'm not sure what you mean by EBP" and acknowledging unfamiliarity with differences between various precaution types.
Facility Response and Ongoing Monitoring
The inspection occurred between April 21 and May 6, 2025, with federal surveyors documenting multiple deficiencies requiring immediate correction. The facility must submit detailed correction plans addressing each identified violation.
Concordia Nursing & Rehab must demonstrate sustainable improvements in medical records management, staffing oversight, and infection control procedures. State surveyors will conduct follow-up inspections to verify compliance with federal nursing home regulations.
The complete federal inspection report provides additional details about specific violations and required corrective actions for this 72714-area facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia Nursing & Rehab, LLC from 2025-05-06 including all violations, facility responses, and corrective action plans.
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