Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concordia Village Care Center during CMS and state inspections, most recent first.
Hand hygiene and glove-use failures were observed during resident care and food service. CNAs served meals, fed a resident with bare hands, handled food and kitchen surfaces with the same gloves, and provided incontinent care without changing gloves or performing hand hygiene between contaminated and clean tasks. A cook and dietary manager also handled food and kitchen items without observed hand hygiene, and staff interviews confirmed expected hand hygiene practices before and after glove use and meal assistance.
A resident with Parkinson's disease, dementia, hallucinations, aphasia, dysphagia, and severe cognitive impairment, who was dependent on staff for mobility and had a care plan calling for comforting 1:1 interaction, was subjected to verbal abuse by a CNA. Video monitoring showed that while the resident was naked and being prepared for a shower with a mechanical lift, the CNA responded to an episode of urinary incontinence with a disparaging remark. In a separate episode, the CNA provided care while on a personal cell phone on speaker mode, using explicit and profane language within the resident’s hearing. The facility’s leadership and abuse policy confirmed these actions met the definition of verbal abuse.
Two residents with severe cognitive impairment and significant mobility limitations experienced multiple falls after the facility failed to consistently implement care-planned fall-prevention interventions and to reassess fall risk following each fall. One resident, dependent for bed mobility and transfers, had documented falls related to rolling in bed and reaching for an item, yet continued to be scored as low fall risk with no post-fall risk assessments completed, and her ordered body pillow was not in place during observation. Another resident with hemiplegia and heart failure had several falls from bed and wheelchair associated with confusion, impaired communication, and self-transfer, but remained classified as low fall risk without new evaluation, and was observed in bed wearing non-grip socks and without the care-planned body pillow, despite staff describing interventions such as body pillow use, fall mat, and frequent checks.
A resident with a history of cardiac disease, pulmonary emboli, and atrial fibrillation was admitted on Warfarin, but the anticoagulant was not entered into the EMR and was not administered for five days. Nursing staff later discovered that Coumadin appeared on all discharge instructions and that multiple Coumadin doses were present in the medication room, yet no active order had been transcribed before a new order was obtained. The DON reported that the required 24‑hour admission audit, intended to verify and reconcile physician orders, was not completed until several days after admission, and staff used a faxed pre‑admission medication list without reconciling it with the updated orders that arrived with the resident, contrary to facility medication reconciliation and admission policies.
A CNA provided incomplete incontinent care for a severely cognitively impaired resident with a history of UTI, Parkinson's disease, aphasia, and heart failure. The CNA did not perform hand hygiene before donning gloves, did not cleanse the inner labia/urethra area after a bowel movement, and used the same gloves to handle skin cream and apply it before placing a clean brief. The DON stated female residents' inner labia should be cleansed after an incontinent episode and hand hygiene and glove changes should occur before, during, and after care.
Food was not served at a safe and appetizing temperature for a resident with quadriplegia, anxiety disorder, and malaise who was cognitively intact. The resident reported that meals served in her room were not warm enough, and observation showed hot items on the test tray had dropped below the facility’s 135-degree F hot-holding standard after residents were served. The DON, Cook, and Dietary Manager all confirmed the hot-food holding expectation.
Failure to perform hand hygiene and glove changes during food service. A Cook was observed serving meals with the same gloves throughout lunch preparation and distribution, touching food, equipment, and surfaces without hand hygiene. A Dietary Manager served food to a resident without hand hygiene or gloves, and a CNA delivered and prepared a resident’s meal, including cutting food and handling drinks, without hand hygiene before, during, or after the task. Staff interviews confirmed expected hand hygiene and glove use practices, and facility policies required handwashing before and after handling food and assisting residents with meals.
The facility failed to properly label, date, and store food items, and did not enforce hygiene practices, such as wearing beard nets, potentially affecting all 51 residents. Observations revealed unlabeled and undated food in various kitchens, improper storage, and personal food items in resident refrigerators. The Dietary Manager confirmed these practices were against facility policies.
The facility failed to dispose of medications for two residents, leading to a deficiency in medication storage. An LPN found medications for a discharged resident still in storage, and the DON noted that another resident's prescription cards, which should have been used or sent home, were improperly stored. The facility's policy requires discontinued medications to be destroyed or returned, which was not followed.
The facility failed to follow infection control protocols for two residents. An LPN did not perform hand hygiene before administering medication, and a resident with COVID-19 lacked necessary isolation and PPE signage on their door, contrary to facility policies.
A resident with dementia and a history of falls experienced a delay in treatment for a humeral fracture due to inadequate communication and assessment by facility staff. Despite complaints of arm pain and unusual behavior, the resident's condition was not reported to the physician until the following day, resulting in a delay in care. The facility's policy for prompt notification of changes in a resident's condition was not followed.
Hand Hygiene and Glove Use Failures During Resident Care and Food Handling
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program during resident care and food service activities. During lunch service, a CNA donned gloves without performing hand hygiene, served a resident’s meal, removed the gloves, handled the refrigerator and ketchup with bare hands, then put on another pair of gloves without hand hygiene before delivering and setting up another resident’s meal tray. Another CNA also donned gloves without hand hygiene, delivered a meal tray, removed the gloves, and then assisted a resident with eating while using bare hands, including feeding the resident a hamburger and french fries and tucking hair behind an ear during the meal. The resident was documented as unable to complete the Brief Interview for Mental Status and dependent on staff for eating. A separate CNA applied gloves without hand hygiene and then touched chair arms before feeding a resident french fries with the same gloved hand. The resident had diagnoses including muscle weakness and Parkinson’s disease. In another observation, a CNA delivered lunch plates and drinks, cut up a resident’s hamburger, removed plastic wrap from drinks and dishes, placed straws in cups, and served residents at the table without hand hygiene being observed before, between, or after these tasks. Staff interviewed stated hand hygiene should be performed before and after glove use and before and after assisting residents with meals. During incontinent care, a CNA donned gloves without hand hygiene, removed a soiled adult diaper containing feces, cleansed the resident’s thighs and buttock, did not cleanse the inner labia/urethra region, continued care while the resident had a bowel movement, and then used the same gloves to reach into a nightstand drawer for skin cream and apply it before placing a diaper on the resident. In the kitchenette, a cook put on gloves without hand hygiene and kept the same gloves on while handling food, opening cabinets and the refrigerator, operating equipment, rinsing dishes, wrapping and storing food, wiping counters, and touching clothing. The dietary manager also handled food with no hand hygiene or gloves observed, and a CNA delivered and prepared food items for residents without hand hygiene being observed.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during the provision of care. The resident had diagnoses including Parkinson's disease, dementia, visual hallucinations, aphasia, dysphagia, and an anxiety disorder with hallucinations, and was documented as severely cognitively impaired and dependent on staff for mobility. The resident’s care plan included interventions such as using touch to provide comfort and offering 1:1 interaction. Video footage from an electronic monitoring device in the resident’s room, reviewed by the resident’s spouse and later by the DON, showed that while the resident was naked and being prepared for a shower with a mechanical lift sling, the resident experienced urinary incontinence and the CNA responded by saying, “Girl, of course you would pee right now. Right now, of all the times in the world!” In a separate incident captured on video, the same CNA was providing care to the resident while simultaneously using her personal cell phone on speaker mode in the resident’s presence. During this call, the CNA used explicit and profane language, including statements such as, “It is so f*****g the bomb. Oh, my f*****g God. I'm trying to make all this shit make sense.” The facility’s abuse/neglect policy defines verbal abuse as the use of oral, written, or gestured language that includes disparaging and derogatory remarks to residents or their families within their sight or hearing, regardless of the resident’s ability to comprehend. The DON and Administrator both confirmed that their investigation substantiated that verbal abuse occurred toward this resident by the CNA.
Failure to Implement Fall-Prevention Interventions and Reassess Fall Risk After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and accurate fall risk assessments for two residents with severe cognitive impairment and significant physical limitations. One resident was admitted with dysphasia, drug-induced Parkinsonism, and COPD, and her MDS documented severe cognitive impairment and dependence on staff for bed mobility and transfers, with several transfer items unable to be completed due to illness or injury. Her care plan identified her as at risk for falls and included interventions such as a body pillow while in bed and a fall mat next to the bed. Despite this, adverse event documentation showed she fell on two occasions, once after rolling over in bed due to improper positioning and once after sliding out of bed while trying to reach a bear that had fallen. At the time of surveyor observation, the body pillow intervention was not in place in her room, and the LPN assisting with her transfer acknowledged not knowing where the body pillow was or why it was not present. The same resident’s fall risk assessments, completed on multiple dates, consistently documented her as a low fall risk and indicated she had not had any falls, even though she had documented falls on two separate dates. No fall risk assessments were completed following either of these falls, contrary to the care plan directive that fall risk assessments be completed on admission, quarterly, with significant changes, and with falls. The Administrator stated that any resident who had fallen in the last six months would not be considered a low fall risk and characterized the body pillow intervention added after one of the falls as new, although the tool had been previously listed. The DON stated she expected staff to follow fall interventions, and the facility’s Management of Falls policy required staff to identify and implement interventions based on resident-specific risks and causes. A second resident, admitted with hemiplegia, heart failure, and muscle weakness, also had an MDS documenting severe cognitive impairment and a need for substantial/maximal assistance with bed mobility and all transfers. His care plan identified him as at risk for falls and included interventions such as side rails as enablers, reminders for safety awareness, locking brakes before transfers, non-skid socks, appropriate footwear, fall risk assessments on admission, quarterly, and with significant changes, placement where visible to staff, frequent checks beginning in the morning to see if he was ready to get out of bed, use of a body pillow for positioning, ensuring the call light and personal items were in reach, and toileting assistance every 1–2 hours. Adverse event documentation recorded multiple falls, including being lowered to the floor from the edge of his wheelchair, being found hanging out of bed with his knees on a floor mat, and being found on the floor with two skin tears, with contributing factors such as confusion/memory deficit, change in mental status, impaired communication, altered gait/balance, and improper/self-transfer. Despite these events, his fall risk assessment documented him as a low fall risk with no new evaluation completed. During observation, an LPN left him in bed wearing socks without grips and without a body pillow in place, while CNAs described his fall interventions as including a body pillow, fall mat, call light in reach, and frequent checks, and reported he was very unsteady, incontinent, and sometimes got up without using his call light.
Failure to Reconcile Admission Orders Resulting in Missed Warfarin Doses
Penalty
Summary
A cognitively intact resident with multiple significant diagnoses, including aortic valve replacement, pulmonary emboli, atrial fibrillation, atherosclerotic heart disease, diabetes mellitus type 2, lung cancer, BPH, depression, and COPD, was admitted on 12/15/25 with orders for Warfarin (Coumadin). The resident’s care plan documented anticoagulant use and risk for bleeding, and the MDS showed the resident required partial to moderate assistance with ADLs. Despite having Warfarin on the admission medication list and on all discharge instructions, there was no Warfarin order entered into the facility’s system prior to 12/20/25, and the resident went five days without receiving the ordered anticoagulant. On 12/20/25 at 8:50 PM, during a chart audit, nursing staff identified that Coumadin appeared on all discharge instructions but had not been entered as an active order, and multiple different doses of the resident’s Coumadin were found in the medication room. An on‑call physician was contacted, and new orders were obtained for Warfarin 10 mg once, followed by 5 mg the next day and repeat INR testing. The resident’s INR on 12/20/25 was 1.1, with subsequent INRs of 1.7 on 12/22/25, 2.2 on 12/23/25, 4.0 on 12/30/25, and 1.9 on 1/2/26. The facility’s documentation notes that the resident had Warfarin orders upon admission that were not entered, resulting in the missed doses. Interviews with facility staff revealed that the admission process was not followed as required. The DON stated that an admission audit, which should be completed within 24 hours of arrival to verify that all physician orders are entered, was not done until five days after the resident’s admission. Nursing staff reported that, at admission, nurses are to fax all physician orders to the pharmacy for entry into the EMR and then double‑check by acknowledging each medication, but in this case, the medication list faxed prior to admission was used instead of reconciling it with the updated orders that arrived with the resident. The facility’s own policies on medication reconciliation and admission assessment require reconciling the medication history, admitting orders, previous MAR, and discharge summary, and contacting the physician if discrepancies are found, but the two sets of orders for this resident were not reconciled, leading to the Warfarin omission.
Incomplete Incontinent Care and Improper Hand Hygiene
Penalty
Summary
The facility failed to provide complete incontinent care for one resident reviewed for incontinent care. The resident had diagnoses including urinary tract infection, Parkinson's disease, aphasia following cerebral infarction, and hypertensive heart disease with heart failure, and the MDS documented severe cognitive impairment. The care plan identified the resident as occasionally incontinent and needing assistance with ADLs related to decreased mobility and muscle weakness. During observation of incontinent care, a CNA donned gloves without performing hand hygiene first, removed the resident's adult diaper soiled with a small amount of feces, cleansed the inner thighs and buttock area, but did not cleanse the inner labia/urethra region. The resident continued to have a bowel movement while the buttock area was being cleansed. The CNA then used the same gloves to reach into the resident's nightstand drawer, obtain skin cream, apply it, and place a clean adult diaper on the resident. The DON stated she would expect CNAs to cleanse the inner labia region after an incontinent episode and to perform hand hygiene and change gloves before, during, and after providing incontinent care.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
Food and drink were not served at a safe and appetizing temperature for one resident, R37, who was admitted with diagnoses of quadriplegia, anxiety disorder, and malaise and was documented as cognitively intact. R37 stated that food served in her room was not the warmest and could be warmer. During lunch observation, the steam table temperatures for seafood crepe, quiche, and potato wedges were recorded at 185 degrees, 145 degrees, and 145 degrees Fahrenheit, respectively, but when the test tray was checked after all residents had been served, the same items had dropped to 129.5 degrees, 131 degrees, and 123.4 degrees Fahrenheit. The Administrator, Cook, and Dietary Manager each stated that hot foods are expected to be held at 135 degrees Fahrenheit or above, and the facility's Food Handling policy stated that food will be stored, prepared, handled, and served to minimize the risk of foodborne illness.
Failure to Perform Hand Hygiene and Glove Changes During Food Service
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety by not performing hand hygiene and not changing gloves during meal service. During lunch observation in the kitchenette, a Cook put on blue gloves after bringing up the warming cart without any hand hygiene observed, then continued using the same gloves while getting plates from the warmer, removing lids and plastic wrap, handling food with his hand instead of tongs, opening cabinets and the refrigerator, operating the mixer/blender, rinsing dishes, wrapping and putting away food items, wiping counters, and preparing additional residents’ plates. He was also observed touching the tops of cups and pulling up his pants while still wearing the same gloves. The Dietary Manager was observed using a scoop from a container of peas and cauliflower to place food in a bowl and deliver it to a resident without hand hygiene or gloves, and the same scoop was then used again for additional dishes. A CNA was also observed delivering lunch plates and drinks, cutting up a resident’s hamburger, removing plastic wrap from drinks and dishes, placing straws in cups, and serving the resident without hand hygiene before, during, or after the task. Staff interviews showed that CNAs and an LPN stated they would wash their hands before donning gloves and after doffing gloves, and the DON stated she expected CNAs to perform hand hygiene and change gloves as needed. The facility’s hand hygiene and food sanitation policies required handwashing before and after handling food, before and after assisting a resident with meals, after removing gloves, and when entering or re-entering the kitchen.
Deficiencies in Food Labeling, Storage, and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food labeling, storage, and hygiene practices, which could potentially lead to foodborne illness affecting all 51 residents. During an inspection, it was observed that the main kitchen's walk-in refrigerator contained a container of meat that was neither labeled nor dated. Additionally, a metal sheet pan with a frozen bag of red pasta sauce was found on the floor of the main kitchen freezer. In various hall kitchens, numerous food items, including premade salads, cottage cheese, tartar sauce, fruit cups, applesauce cups, frozen meat, waffles, breakfast sausage, and squeeze bottles of liquid butter and syrup, were found unlabeled and undated. Open and unsealed boxes of cream of wheat were also noted. Employees were found to be storing personal food items in refrigerators meant for residents. Furthermore, the facility did not ensure that staff adhered to hygiene standards, as observed during a meal service where two cooks were not wearing beard nets while handling food. The Dietary Manager acknowledged that all food products should be labeled with the name, date prepared, and expiration date, and that employees should not use resident refrigerators for personal food. The facility's policies on food storage and preventing foodborne illness were not followed, as evidenced by the lack of labeling, dating, and proper sealing of food items, as well as the absence of required hair and beard restraints.
Medication Disposal Deficiency
Penalty
Summary
The facility failed to properly dispose of medications for two residents, leading to a deficiency in medication storage practices. During an inspection of the medication storage room, it was observed that there were three Lantus Pens and a vial of 100 units for a resident who had been discharged from the facility. The Licensed Practical Nurse (LPN) confirmed that the resident had not been in the facility for some time and stated that old medications are typically destroyed, as the pharmacy does not accept them for refund. This indicates a lapse in the facility's protocol for disposing of medications belonging to discharged residents. Additionally, another resident had five prescription cards stored in the medication room, with dispense dates ranging from February to April. The Director of Nursing (DON) stated that these prescription cards must have come from the resident's home, as the facility does not use prescription cards. The DON acknowledged that these medications should have been used first or sent home with the resident's family, especially since the resident had been moved to a different hall. The facility's policy on discarding and destroying medication requires that discontinued medications be either destroyed or returned, which was not adhered to in these cases.
Infection Control Deficiencies in Hand Hygiene and PPE Signage
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for two residents. In the first instance, a Licensed Practical Nurse (LPN) administered medication to a resident without performing hand hygiene before donning gloves, which is against the facility's hand hygiene policy. The Director of Nursing confirmed that hand hygiene should be performed before applying non-sterile gloves. In the second instance, a resident who tested positive for COVID-19 did not have the required isolation and personal protective equipment (PPE) signage on their door. The Director of Nursing acknowledged that the signage indicating necessary PPE should have been posted, as per the facility's COVID-19 infection prevention control measures policy.
Delay in Treatment for Resident's Humeral Fracture
Penalty
Summary
The facility failed to provide timely assessment and treatment for a resident's humeral fracture, resulting in a delay of care. The resident, who was admitted with diagnoses including dementia, depression, muscle weakness, osteoporosis, and a history of falling, was noted to have right arm pain and unusual behavior on the morning of 6/12/24. Despite these observations, the resident's condition was not promptly addressed, and the pain and bruising were not reported to the physician until the following day. On 6/12/24, several staff members, including CNAs and an RN, observed the resident's unusual behavior and complaints of arm pain. However, the information was not effectively communicated or acted upon. A CNA noticed the resident's right arm hanging unusually and bruising while preparing the resident for bed, but the LPN on duty did not take immediate action, instead suggesting the CNA check with other nurses. The shift change report notes did not adequately document the resident's condition, leading to a lack of follow-up. The resident's condition was finally addressed on the morning of 6/13/24 when a CNA noticed extensive bruising and reported it to an LPN, who then notified the ADON and the physician. An X-ray was ordered, revealing a comminuted fracture of the right humerus. The facility's policy required prompt notification of the physician for changes in a resident's condition, which was not adhered to in this case, resulting in a delay in treatment.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Suites Rehab And Nursing | 1.5 mi | ★★★★★ | 15 | 0 |
| Arc At Sangamon Valley | 2.2 mi | ★★★★★ | 9 | 0 |
| Regency Care | 3.1 mi | ★★★★★ | 1 | 0 |
| Arcadia Care On The Hill | 4.5 mi | ★★★★★ | 4 | 0 |
| Avenues At Springfield | 5.3 mi | ★★★★★ | 4 | 0 |
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