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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Concord during CMS and state inspections, most recent first.
Inaccurate Documentation of Wound Care and Skin Prep: Two residents had inaccurate charting in the TAR. One resident’s healed buttock pressure ulcer was still documented as receiving dressing changes with drainage, even though staff confirmed the wound had healed and no dressing was applied. Another resident with a below-knee amputation was documented as receiving skin prep to bilateral heels, but staff confirmed the charting was inaccurate because the resident does not have a right heel.
Unlabeled pre-poured medications were found in medication carts, including controlled substances mixed with applesauce and other pills, and a liquid medication that had been poured early for later use. An LPN on one unit and another nurse on a different unit both stored medications in uncovered cups instead of keeping them in the original labeled containers, and the DON said staff were expected to follow the facility's medication storage policy.
A nurse witnessed a CNA slap a cognitively impaired resident and, instead of intervening or ensuring the resident's safety, left the resident alone with the accused staff member to report the incident. This action did not follow the facility's abuse policy, which requires immediate protection of residents and separation from alleged perpetrators during investigations.
The facility failed to develop personalized care plans for two residents, leading to deficiencies in their care. One resident with dementia and dysphagia did not have the Speech Therapist's recommendations incorporated into their care plan, resulting in incidents of choking and food pocketing. Another resident with alcohol abuse and schizoaffective disorder lacked a comprehensive care plan addressing their substance use disorder. The Director of Nurses confirmed these deficiencies should have been addressed.
A facility failed to maintain accurate documentation for a resident with dementia and Parkinson's disease. The resident's care plan required checking a wanderguard every shift, but the MAR for January 2025 showed 19 incorrect entries indicating the wanderguard was not in place or functioning. A nurse admitted to making 15 of these incorrect entries, and the DON confirmed the expectation for accurate documentation.
Inaccurate Documentation of Wound Care and Skin Prep
Penalty
Summary
The facility failed to accurately document care in the medical record for two sampled residents. For Resident #6, who was admitted with diagnoses including heart failure and peripheral vascular disease and had moderate cognitive impairment, the record showed a left buttock pressure ulcer that had resolved on 12/29/25. However, the Treatment Administration Record documented that a left buttock dressing change was completed on multiple dates and described scant serous drainage, even though the wound had healed and no dressing was present when observed with the ADON. The ADON and Nurse #1 both stated the wound had healed and that the documentation of dressing changes and drainage was inaccurate. For Resident #10, who was admitted with diagnoses including acquired absence of the right leg below the knee and muscle weakness and was moderately cognitively impaired, the physician order directed skin prep to bilateral heels every day and evening shift. The TAR showed nurses signed off that skin prep had been applied to the bilateral heels twice daily, but Nurse #1, the nursing supervisor, and the DON stated this was inaccurate because the resident does not have a right heel due to the below-knee amputation. The documentation therefore reflected treatment being provided to a body part that was not present.
Unlabeled pre-poured medications stored in medication carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws and its own medication storage policy. Review of the policy titled "Medication Labeling and Storage" showed that medications and biologicals are to be stored in the packaging, containers, or other dispensing systems in which they are received, and that controlled substances and other drugs subject to abuse are to be separately locked in permanently affixed compartments. On 1/7/26, a surveyor observed the Dove Unit medication cart with Nurse #2 and found three uncovered, unlabeled medication cups containing pre-poured medications. Nurse #2 stated she had pre-poured the medications before attempting to administer them later. One cup contained an Ativan pill mixed with other pills in applesauce, another contained an Ativan pill in applesauce for a different resident, and a third contained a pink liquid medication that Nurse #2 said she had poured early because it was supposed to be refrigerated. The Ativan pills were controlled substances and were not stored in separately locked compartments. Later that day, the surveyor observed the Cardinal Unit medication cart #1 with Nurse #3 and found one uncovered, unlabeled medication cup containing four pills that had been prepared earlier in the shift and saved for later administration after the resident was not ready to take them. Nurse #3 stated the medications should have been discarded because they should not be stored this way in the medication cart. The DON stated she expected nurses to follow the facility's medication storage policy.
Failure to Protect Resident After Witnessed Abuse Incident
Penalty
Summary
A deficiency occurred when a nurse witnessed a certified nurse aide (CNA) slap the left side of a resident's face with an open hand. The resident involved had severe cognitive impairment. After witnessing the incident, the nurse left the resident and the accused CNA alone in the room and immediately went to report the incident to the nurse manager, rather than intervening or ensuring the resident's immediate safety by separating them from the alleged perpetrator. The facility's abuse policy required staff to report any signs of abuse immediately and to protect residents from harm during investigations, including reassigning or suspending the accused staff member to prevent further contact with residents. Interviews confirmed that the nurse did not intervene or remain with the resident after witnessing the alleged abuse, and the director of nursing acknowledged that the nurse should have stayed with the resident and asked the CNA to leave. The failure to follow the facility's abuse policy and procedures resulted in the resident, who was cognitively impaired, being left alone with the staff member accused of abuse immediately after the incident.
Failure to Develop Personalized Care Plans for Residents
Penalty
Summary
The facility failed to develop personalized care plans for two residents, leading to deficiencies in their care. For Resident #87, who was admitted with dementia and dysphagia, the facility did not incorporate the Speech Therapist's recommendations into the care plan after evaluations on two separate occasions. The resident experienced incidents of choking and pocketing food, which were not addressed in the care plan despite verbal recommendations from the Speech Therapist to the Unit Manager. These recommendations included supervising the resident during meals, checking for food pocketing, and adjusting the resident's seating in the dining room to ensure visibility to staff. Resident #92, admitted with alcohol abuse and schizoaffective disorder, also lacked a personalized care plan addressing their history of substance abuse. Although the nutritional care plan mentioned alcohol abuse, there was no comprehensive care plan from a mood and behavior perspective. The Social Worker acknowledged the need for a personalized care plan to address the resident's substance use disorder, which was not developed. The Director of Nurses confirmed that the verbal recommendations for Resident #87 and the need for a substance abuse care plan for Resident #92 should have been addressed and incorporated into their respective care plans. The failure to develop these personalized care plans resulted in deficiencies in meeting the residents' needs and ensuring their highest practicable well-being.
Inaccurate Documentation of Wanderguard in Resident's Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident diagnosed with dementia and Parkinson's disease. The resident, who was admitted in September 2023, was identified as having severely impaired cognition and a behavior of wandering. The care plan for the resident included interventions to check the placement and function of a wanderguard on the resident's left ankle every shift. However, the Medication Administration Record (MAR) for January 2025 showed that nursing staff documented 19 instances where the wanderguard was not in place or functioning. During an interview, a nurse who regularly cares for the resident acknowledged that the resident wears a wanderguard due to elopement behavior and does not attempt to remove it. The nurse admitted to incorrectly documenting 15 of the 19 instances as 'no' in the MAR, indicating the wanderguard was not in place or functioning. The Director of Nursing confirmed that it is expected for the MAR documentation to be accurate, highlighting a failure in maintaining accurate medical records as per the facility's policy.
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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 W Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivercrest Long Term Care | 0.5 mi | ★★★★★ | 0 | 0 |
| The Commons Skilled Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 9 | 0 |
| Life Care Center Of Acton | 4.1 mi | ★★★★★ | 0 | 0 |
| Campion Health & Wellness, Inc | 5.8 mi | ★★★★★ | 0 | 0 |
| Carleton-willard Village Retirement & Nursing Ctr | 6.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.