Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concord Care Center during CMS and state inspections, most recent first.
A resident with intact cognition but significant physical limitations from CVA, hemiplegia/hemiparesis, and limited ROM required substantial assistance with toileting and dressing and dependent transfers per the care plan. During morning care, a CNA told the resident it was time to get up, placed clothes in the wheelchair, and left without assisting, returning about 20 minutes later and stating she had other people to take care of when the resident asked for help. The resident, feeling upset and worthless, struggled to move furniture, dress, and transfer to the bathroom using grab bars without the required assistance, and later reported the CNA’s rude comments and lack of help to several staff. Another CNA observed the resident crying and striking the bed in frustration and viewed the situation as a respect and dignity issue. A trauma screening documented the resident’s history of prolonged verbal and physical abuse, but the care plan lacked a post-trauma focus or interventions despite this background and the resident’s distress.
A resident with dementia, chronic pain, and significant ADL dependence allegedly had their hands slapped by a CNA during incontinent care while the resident was yelling, crying, and swinging at staff. The witnessing CNA, despite having dependent adult abuse training and recent in‑service education on abuse reporting, did not immediately report the allegation to a charge nurse or Abuse Coordinator and instead waited and discussed it with another CNA later. The Administrator was not informed until much later, and the allegation was not reported to the state survey agency within the required 2‑hour timeframe, contrary to facility policy requiring immediate reporting of all abuse allegations.
A resident with CHF, renal failure, diabetes, and adult failure to thrive, who was care planned as at risk for ineffective breathing, developed a worsening cough, chest pain from coughing, fatigue, decreased appetite, and crackles in both lungs while using PRN albuterol nebulizers. Over the next shift the resident remained in bed, felt unwell, had poor intake, and later requested transfer to the hospital. Despite these changes, the clinical record contained no further assessment documentation, including no recorded lung sound assessments, even though abnormal respiratory findings were present. EMS later found the resident with labored breathing and an SpO2 of 83%, and the hospital documented acute hypoxic respiratory failure, suspected aspiration pneumonia, acute bronchitis with bronchospasm, RSV positivity, and generalized weakness. An RN acknowledged the lack of lung sound documentation despite it being an expected nursing practice and noted there was no specific assessment policy tied to change in condition.
A resident with multiple chronic conditions reported severe pain and bright red blood in his catheter bag, but staff did not document an assessment of the complaint and waited for provider direction before the resident was sent to the ER. The resident later said he had severe abdominal pain, urinary retention, and was told he could not go by ambulance because it was not life threatening. The facility also failed to document adequate monitoring for another resident receiving IV Vancomycin via PICC line, with only one set of VS recorded and no evidence of daily monitoring on the MAR/TAR.
The facility failed to ensure the QA/QAPI committee included all required members at quarterly meetings. Record review showed the first QA meeting had no Medical Director or designee present, and the Administrator acknowledged this omission. The facility's QAPI policy required the NHA or representative, DON, Medical Director or representative, and two other staff members to attend at least quarterly.
A facility failed to complete a follow-up PASRR and resubmit it for reevaluation for a resident with mental disorders, including anxiety, depression, bipolar disorder, and schizophrenia. The resident's PASRR expired, and a subsequent Level 1 screen was submitted over four months late, causing a compliance issue. The delay was due to the Administrator performing dual roles, leading to the late resubmission of the PASRR.
The facility failed to provide adequate staffing, resulting in delayed call light responses for three residents. A resident with intact cognition reported waiting up to 45 minutes for assistance, risking incontinence. Another resident with moderate cognitive impairment experienced anxiety due to long wait times, particularly on weekends. A third resident, requiring assistance for transfers and toileting, reported inconsistent response times, leading to incontinence. Staff interviews confirmed that staffing levels and response times varied, with some acknowledging the delays.
The facility did not comply with regulatory requirements for QAA meetings due to the absence of the Infection Preventionist (IP) on multiple occasions. The IP's signature was missing from meeting documents, and the Administrator confirmed the IP was working on the floor during these meetings, despite the facility's QAPI Plan requiring their attendance.
A resident with a pressure ulcer did not have enhanced barrier precautions in place, and staff failed to wear gowns during high-contact care activities. Additionally, a staff member did not perform hand hygiene after removing gloves following peri care. The DON confirmed these lapses, which were against the facility's infection prevention policy.
A resident with severe cognitive impairment and multiple health conditions experienced repeated falls due to the facility's failure to implement effective interventions and provide necessary assistance as outlined in the care plan. Despite being at risk for falls, the resident was left unattended in the dining room, leading to multiple incidents and injuries. The facility's policy required fall risk assessments and communication of interventions, but these were not effectively followed.
Failure to Provide Dignified Morning Care and Respect Resident’s Need for Assistance
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity during morning care. The resident had a history of CVA with hemiplegia/hemiparesis, limited range of motion on one side, cataracts, and required substantial to maximal assistance for toileting hygiene and dressing, and was dependent for transfers. Her care plan called for staff assistance with ADLs, including one staff member to assist with dressing/grooming, assistance with toileting per her routine, and two staff with an EZ stand for transfers. Despite these documented needs, a CNA entered the resident’s room early in the morning, told her it was time to get up, placed her clothes in the wheelchair, and left without providing the needed assistance. According to the resident’s account, the CNA did not return for approximately 20 minutes. During this time, the resident, who required significant assistance, attempted to move her bedside table, sit at the edge of the bed, reach her wheelchair, and get herself dressed and to the bathroom without help. When the CNA returned and saw the resident was not yet up and dressed, the CNA reportedly told the resident she had other people to take care of and did not assist, leaving again. The resident reported feeling mad, worthless, and like “nothing and a nobody” as she struggled to get to the bathroom and use the grab bar to transfer herself to the toilet. When the CNA came back and found the resident in the bathroom, the CNA questioned what the resident was doing there by herself and then assisted with putting on the brief and pants. The resident reported this interaction to multiple staff members and described the CNA’s behavior and comments as rude and upsetting, though she did not personally label it as abuse. Another CNA reported that the resident was visibly upset, crying, and hitting the top of the bed in frustration while recounting the incident, and characterized the concern as one of respect and dignity. The facility’s own Resident Rights–Dignity and Respect policy states that each resident has the right to considerate and respectful care and to be treated with dignity and respect, with reasonable accommodation of individual needs. Additionally, a trauma screening documented that the resident had a history of verbal and physical abuse by her husband for 11 years, but the care plan did not include a post-trauma focus or related interventions, despite this history and the resident’s emotional response to the incident.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was reported to the state survey agency within the required 2-hour timeframe. The facility’s own policy, dated 9/2025, requires that all allegations of resident abuse be reported immediately to the charge nurse, who must immediately notify the Administrator or designee, and that all allegations be reported to the Iowa Department of Inspection and Appeals and Licensing immediately and not later than two hours. In this case, an alleged incident of mistreatment involving verbal and physical abuse occurred on 3/10/26 during evening shift care for Resident #10, but the allegation was not brought to the Administrator’s attention until 4/11/26 and was not reported to the state agency until 4/12/26. Resident #10 had non-Alzheimer’s dementia, hypertension, heart failure, anxiety, depression, adult failure to thrive, chronic lower back pain, and moderate cognitive impairment with a BIMS score of 10. The resident required partial to moderate assistance with all ADLs, substantial to maximal assistance for bed mobility, and had a history of being impulsive and at times resistive to care, including hitting, screaming, and biting at staff during care or transfers. On 3/10/26, while two CNAs were providing incontinent care, one CNA later reported that the other CNA was very fast and rough when rolling the resident, and that the resident was yelling, screaming, and crying. The reporting CNA stated that the other CNA took the resident’s hands and slapped them while telling the resident that cares needed to be completed, during a time when the resident was hitting and swinging at staff. Despite having completed dependent adult abuse reporting training and facility education on abuse reporting on 4/10/26, the CNA who witnessed the alleged slapping did not immediately report the incident to a charge nurse or Abuse Coordinator. Instead, she waited until 4/11/26 to call another CNA to discuss the situation, at which point she was told it needed to be reported to the Administrator. The Administrator was then notified, and the allegation was reported to the state agency on 4/12/26, more than a month after the alleged incident and well beyond the 2-hour reporting requirement. Interviews with staff and review of the facility’s policy confirmed that all allegations or accusations of abuse were expected to be reported right away, but this did not occur in this case, resulting in the cited deficiency for failure to timely report suspected abuse.
Failure to Assess and Document Respiratory Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate assessment and care for a resident experiencing a change in condition. The resident had intact cognition, multiple chronic diagnoses including CHF, renal failure, diabetes, and adult failure to thrive, and a care plan identifying risk for ineffective breathing pattern related to CHF with interventions such as evaluating for shortness of breath, respiratory rate, and effort. Health Status Notes show that the resident requested cough medicine for a dry cough, later reported a productive cough with chest pain from coughing all night, difficulty getting comfortable, decreased appetite, fatigue, and crackles in bilateral lung lobes, and had been using PRN albuterol nebulizers. Later documentation indicated the resident had not been feeling well, remained in bed, refused to get out of bed except for the bathroom, had poor appetite, and staff were encouraging fluids. In the early morning, the resident requested to go to the hospital, and the provider ordered transfer by ambulance. However, the clinical record lacked documentation of any further assessment of the resident’s change in condition, including the absence of documented lung sound assessments despite abnormal respiratory symptoms. EMS records described the resident as in a lateral recovery position, holding a garbage can off the side of the bed, having labored breathing, and an oxygen saturation of 83%. The hospital encounter documented shortness of breath, generalized weakness, coughing with sputum, RSV positivity, hypoxia, and principal problems including acute hypoxic respiratory failure, suspected aspiration pneumonia, acute bronchitis with bronchospasm, and generalized weakness. A facility RN acknowledged that the clinical record lacked documentation of lung sounds and confirmed that documenting abnormal lung sounds is an expectation of nursing practice, and that while the facility had a change of condition policy, it did not have a specific policy for assessments to be completed.
Failure to Assess Catheter Bleeding and Monitor IV Antibiotic Therapy
Penalty
Summary
The facility failed to ensure adequate assessment and timely intervention when a resident with a history of heart failure, peripheral vascular disease, diabetes, stroke, pacemaker, and a below-the-knee right leg amputation reported severe pain and bright red blood in his urinary catheter bag. The resident, who was cognitively intact, repeatedly told staff that he was "pissing straight blood" and that it hurt "like hell." The nurse contacted the provider’s office and left a voicemail, but the clinical record lacked documentation of any assessment related to the resident’s complaints of pain or bleeding. The resident became increasingly upset while waiting for a response and stated he would call 911 himself. The resident’s progress notes show that staff, including the DON, SW, and Administrator, went to the resident’s room after he became angry, and the provider eventually returned the call with an order to transfer the resident to the hospital for urinary pain and bleeding. The resident was transported to the ER several hours after first reporting the symptoms. After returning to the facility, the resident was diagnosed with urinary retention, and the catheter that had been in place was replaced with a larger catheter that was documented as draining freely. The resident later stated he had severe low abdominal pain and blood in his catheter, that he was told he could not go by ambulance because it was not life threatening, and that he waited several hours before going to the hospital while in severe pain. The facility also failed to adequately monitor a resident receiving IV antibiotics through a PICC line. The resident had an order for IV Vancomycin for infection and was identified on Enhanced Barrier Precautions related to the PICC line and diabetic ulcer wounds. The record showed vital signs documented only once on the TAR during the month, despite the Infection Preventionist stating that residents on antibiotics should be on hot charting and monitored and documented at least daily, and that residents with PICC lines should have daily vital signs documented on the MAR/TAR. The clinical record lacked documentation that the facility monitored the resident related to the IV antibiotic therapy via PICC line.
QA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QA) committee was attended by the required members on a minimum quarterly basis. Record review showed that the facility provided QA committee meeting sign-in sheets since the last recertification survey on 10/24/25, and the first QA committee meeting was held on 2/28/25. At that meeting, the Medical Director or a designee for the Medical Director was not present. The facility reported a census of 77. On 9/25/2025 at 2:24 PM, the Administrator acknowledged the concern that the Medical Director or his/her designee was not in attendance for the February QA meeting. The facility's QAPI policy dated 10/2023 stated that the QAPI team must include the NHA or representative, DON, Medical Director or representative, and 2 other staff members, and that the members of the QAPI committee must meet at least quarterly and as needed.
Failure to Timely Resubmit PASRR for Resident with Mental Disorders
Penalty
Summary
The facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) and resubmit it to ASCEND for reevaluation for a resident with mental disorders and intellectual disabilities. The resident, who was diagnosed with anxiety disorder, depression, bipolar disorder, and schizophrenia, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident was admitted to the facility with a Level 1 PASRR that expired after 60 days, and a subsequent Level 1 PASRR indicated the need for a Level II onsite evaluation. However, the Level 1 screen was submitted over four months after the prior PASRR expired, leading to a compliance issue. The facility's failure to timely resubmit the PASRR was attributed to the Administrator, who was also performing the duties of a Social Worker during the period in question. This dual role led to delays in the resubmission process, resulting in the resident's PASRR being completed after the expiration of the short-term approval period. The facility's procedures required the Level I screen to be electronically submitted before admission to a Medicaid-certified nursing facility and prior to the conclusion of an assigned time-limited stay, which was not adhered to in this case.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by prolonged call light response times for three residents. Resident #24, with intact cognition, reported waiting up to 45 minutes for assistance, risking incontinence. The call light report confirmed multiple instances where response times exceeded 15 minutes, with some reaching up to 45 minutes. Resident #22, with moderately impaired cognition, also experienced long call light response times, particularly on weekends, which contributed to her anxiety. Her niece expressed concerns about the staffing levels and the impact on her aunt's well-being. The facility's call light report corroborated these delays, with several instances exceeding 30 minutes. Resident #3, who required assistance for transfers and toileting, reported inconsistent call light response times, leading to incontinence. The call light report showed numerous instances where response times were significantly delayed, with some exceeding 30 minutes. Interviews with staff indicated that staffing levels and call light response times varied, with some staff acknowledging the delays.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to meet the regulatory requirements for their Quality Assessment and Assurance (QAA) meetings by not having the minimum number of required members present. Specifically, the Infection Preventionist (IP) was absent from the QAA meetings held on multiple occasions, as evidenced by the lack of the IP's signature on documents dated 5/7/24, 6/2024, 7/2024, 9/10/24, and 10/8/24. The facility's Quality Assurance Performance Improvement (QAPI) Plan, effective March 1, 2024, mandates that the IP, along with other key personnel, attend these meetings at least quarterly. During an interview, the Administrator confirmed the absence of the IP, attributing it to the IP's responsibilities on the floor during the meetings, although the IP's information was reportedly discussed in their absence.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, specifically in the care of a resident with a pressure ulcer. The resident, who had severely impaired cognition and required assistance with transfers and toileting, was observed without an enhanced barrier precaution sign on their door. During care activities, staff members did not adhere to the facility's infection prevention and control guidelines. Specifically, staff did not wear gowns during high-contact activities, such as transferring and providing hygiene care to the resident with a chronic pressure ulcer. Additionally, there were lapses in hand hygiene practices. After providing peri care and removing gloves, a staff member did not perform hand hygiene before continuing with other care tasks. The Director of Nursing acknowledged these deficiencies, confirming that enhanced barrier precautions were not in place and that hand hygiene should have been performed after glove removal. The facility's policy required hand hygiene before and after assisting a resident with toileting and after removing gloves, as well as the use of gowns and gloves during high-contact care activities for residents with chronic wounds.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions and provide the necessary assistance as outlined in the care plan for a resident with severe cognitive impairment and multiple health conditions, including Alzheimer's Disease, depression, heart failure, and hypertension. The resident was assessed as requiring partial or moderate assistance for transfers, ambulation, and toilet transfers. Despite being identified as at risk for falls due to gait and balance problems, the resident experienced multiple falls over a period of time, including incidents in the dining room where the resident was left unattended, contrary to the care plan directives. The care plan included specific interventions such as attaching a call-sensitive light to the resident's blanket, ensuring appropriate footwear, frequent visual checks, and not leaving the resident unattended in the dining room. However, these interventions were not effectively implemented, as evidenced by the resident's repeated falls and injuries, including a laceration and hematoma from an unwitnessed fall. The facility's policy required fall risk assessments and the communication of interventions to staff, but the repeated falls suggest a failure to adhere to these protocols and adequately supervise the resident to prevent accidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Garner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Care Center | 10.3 mi | ★★★★★ | 0 | 0 |
| Oakwood Care Center | 11.5 mi | ★★★★★ | 5 | 0 |
| Good Samaritan - Forest City | 11.7 mi | ★★★★★ | 0 | 0 |
| Kanawha Community Home, Inc. | 14.1 mi | ★★★★★ | 3 | 0 |
| Rehabilitation Center Of Belmond | 16.4 mi | ★★★★★ | 2 | 0 |
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