Concordia at Villa St. Joseph Personal Care.

“Resident support plans did not accurately document assessed care needs and corresponding service plans. Multiple residents had inaccurate assessments: one resident with documented suicidal ideation was assessed as exhibiting no harmful behaviors; another with frequent transfer assistance needs was assessed as needing only verbal prompting; one unable to leave unattended was assessed as being supervised by family; and one with recent suicidal ideation with concrete plan was assessed as exhibiting no harmful behaviors.”

“A resident incident involving physical abuse was not reported to the Department within 24 hours as required. The incident occurred on 5/17/2025 but was not reported to the Department until 5/19/2025, despite being witnessed by multiple staff members at the time of occurrence.”

“A resident was physically abused when staff member A slapped the resident in the face with an open hand at the nursing station after the resident spat at the staff member. This constitutes corporal punishment and physical abuse in violation of resident protection requirements.”

“Carbon monoxide detector was installed approximately 7 feet from a gas-fueled stove in the kitchen, violating the Care Facility Carbon Monoxide Alarms Standards Act requirement of at least 15 feet from any fossil-fuel burning device or appliance.”

“The bed enabler on resident #1's bed was not attached and secured to the bedframe, allowing it to shift approximately 6 inches, posing an entrapment hazard and a fall risk.”

“Brown liquid was observed on the bottom of the silver refrigerator in the main kitchen and on the bottom of the silver freezer located in the serving station on the second floor, failing to maintain sanitary conditions.”

“The freezer section of the white refrigerator in memory care measured 5 degrees Fahrenheit at approximately 11:00 a.m. and 2 degrees Fahrenheit at 3:50 p.m., failing to maintain frozen food at or below 0°F as required.”

“An unsealed bag containing multiple pie crusts was found in the walk-in refrigerator, violating the requirement that food shall be stored in closed or sealed containers.”

“The home services 107 residents requiring a minimum of 321 gallons of emergency drinking water but had only 137 gallons stored on-site. Additionally, the home's emergency drinking water contract did not guarantee priority delivery or specify the amount of water to be delivered in the event of a regional general emergency.”

“Between approximately 3:15 p.m. and 3:24 p.m., the medication cart on the 2nd floor near the nurses station was unlocked, unattended, and accessible to residents, with multiple resident medications accessible including Melatonin, Risperidone, Vistaril Capsule, Levothyroxine, and Trazodone. This is a repeat violation from 4/30/24.”

“Direct care staff A and staff B did not receive 12 hours of annual training for the January 2023 to December 2023 training year as required.”

“An uncovered trash can full of soiled briefs was found in the shared bathroom for bedrooms 2203 left and right, creating a strong fecal odor.”

“The home's most recent supervised fire drill by a fire safety expert was conducted on 12/28/2023, but the previous supervised fire drill was conducted on 10/21/2022, exceeding the annual requirement.”

“Resident #2 has not been evacuated during the home's monthly fire drills since admission on an unspecified date, as confirmed by staff and resident interviews.”

“Multiple unsecured, unattended, and accessible medications were found in resident rooms: Zilactin-B Gel 10% in bedroom #2114 bathroom; Nortitate 1% cream, Triamcinolone cream 0.1%, and Hydrocort Lotion 1% in bedroom 2217 on bedside table and bathroom sink.”

“Resident #3's Lorazepam label indicated dosing of one tablet twice daily but should include the additional as-needed dosing of one tablet every 4 hours. Resident #4's Novolog label did not accurately reflect the prescribed sliding scale dosing and timing.”

“Direct care staff A and staff B did not receive 12 hours of annual training for the January 2023 to December 2023 training year as required.”

“An uncovered trash can full of soiled briefs was found in the shared bathroom for bedrooms 2203 left and right, creating a strong fecal odor.”

“The home's most recent supervised fire drill by a fire safety expert was conducted on 12/28/2023, but the previous supervised fire drill was conducted on 10/21/2022, exceeding the annual requirement.”

“Resident #2 has not been evacuated during the home's monthly fire drills since admission on an unspecified date, as confirmed by staff and resident interviews.”

“Multiple unsecured, unattended, and accessible medications were found in resident rooms: Zilactin-B Gel 10% in bedroom #2114 bathroom; Nortitate 1% cream, Triamcinolone cream 0.1%, and Hydrocort Lotion 1% in bedroom 2217 on bedside table and bathroom sink.”

“Resident #3's Lorazepam label indicated dosing of one tablet twice daily but should include the additional as-needed dosing of one tablet every 4 hours. Resident #4's Novolog label did not accurately reflect the prescribed sliding scale dosing and timing.”

“The home failed to immediately report suspected abuse to the local Area Agency on Aging in accordance with the Older Adult Protective Services Act. Two incidents occurred: (1) one resident choked and struck another resident, and (2) one resident was found in another resident's bed without appropriate clothing. Both incidents involved residents with dementia in the Secured Dementia Care Unit.”

“The home failed to report incidents to the Department's personal care home regional office or complaint hotline within 24 hours. Two separate incidents involving physical abuse between residents in the Secured Dementia Care Unit were not reported to the Department in a timely manner.”

“Residents were physically abused. One resident with dementia choked, struck, and threw another resident with dementia against the wall, causing head injury. Another incident involved one resident punching another resident in the face twice, knocking them to the ground, then using a wheeled walker to pin and strike the victim. The home failed to properly supervise residents who were displaying aggressive, sexually inappropriate, and bullying behaviors toward peers.”

“A resident prescribed medication before meals per sliding scale did not have a glucometer check recorded on the Medication Administration Record for a specific date and time when the medication was administered.”

“A resident's Medication Administration Record did not properly record a prescribed medication increase for transdermal patches to be applied every 72 hours for pain management.”

“The Medication Administration Record did not record the date and time of transdermal patch administrations or removals, including failure to document patch administration and previous patch removal on specified dates.”

“The home failed to follow prescriber's orders including: failure to check glucometer and administer prescribed medication before meals on multiple dates; failure to remove previous transdermal patch when administering new patch; and failure to administer prescribed subcutaneous medication on specified dates due to medication unavailability.”

“The facility failed to report an alleged sexual assault incident to the Department within 24 hours as required. A resident reported being sexually assaulted by a van driver, but the Department was not notified until the inspection date of 11/29/23, rather than within 24 hours of the report.”

“The facility violated requirements related to compliance with regulations, resulting in a civil money penalty.”

“Resident #1 threw resident #2 against a wall on 5/28/23 and grabbed resident #3 by the arms causing bruising on 5/29/23. These allegations of resident-to-resident abuse were not reported to the local Area Agency on Aging as of the inspection date.”

“The facility failed to report alleged abuse incidents to the Department or submit incident reports within 24 hours. Resident #1 threw resident #2 against a wall on 5/28/23 and forcibly grabbed resident #3 causing bruising on 5/29/23, but these incidents were not reported to the Department as of 5/31/23. This is a repeat violation from 11/22/22.”