Concordia Nursing & Rehab, Llc
Concordia Nursing & Rehab, LLC in Bella Vista, AR — inspection on May 6, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F688.
These deficient practices have the potential to affect all the residents residing in the facility.
It was determined the facility ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, S483.70 Administration at a scope and severity of L .
The IJ began on 04/29/2025 after the survey team identified five IJs including
Observation of bed rails on beds, care plans for residents in place; in-service provided to Administrator by Regional Director on 04/30/2025; in-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required; consent forms for residents with bed rails, bed rail assessments for residents with bed rails.
Six (6) residents identified as having bed rails with no assessments / consents.
Assessments and consents obtained.
Monitoring sheets completed on 05/08/2025 by Administrator and Director of Nursing (DON), 05/12/2025 by Housekeeping Supervisor and 05/13/2025 by Administrator and DON, for bed rail assessment and consents.
File containing manufacturer guidelines for bed rails provided.
The Housekeeping Supervisor confirmed they were in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed.
Review of the in-service document date 05/02/2025 revealed the regional director in-serviced the governing body by telephone and the Administrator was in-serviced in person regarding responsibility of the governing body, survey findings, plan of removal to correct findings during survey, and plan moving forward to improve findings. A total of 6 staff interviews were conducted with staff from all shifts verifying training had been completed.
The staff interviewed included Certified Nursing Assistants, Housekeeping Supervisor.
The staff interviewed verified they had been trained on bed rails and enhanced barrier precautions. A review of in-service sheets provided indicated 24 staff were provided with training.
Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
045143
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 045143 B.
Wing 05/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714