Cumberland Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review, and review of facility policies titled Behavioral Health Services and Comprehensive Care Plans the facility failed to ensure a behavioral health care plan was developed with person centered interventions for Resident Identifier (RI) #286 a resident with documented substance abuse and noncompliance of care. This affected RI #286 one of seven residents sampled for behaviors. These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176. Findings Include: Cross reference F741. The facility policy titled Comprehensive Care Plans with an effective date of 04/06/2015 and a last revised date of 02/09/2024 documented: . The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The facility policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and a review of the Facility assessment dated [DATE], the facility failed to ensure substance abuse training was provided to staff. This deficient practice affected Resident Identifier (RI) #286 one of seven residents sampled for behaviors. Findings include: Cross Reference F740 RI #286 was admitted to the facility on [DATE]. RI #286 had diagnoses that included Paraplegia, Muscle weakness, and Stimulant Dependence. RI #286 admission Minimum Data Set (MDS) dated [DATE] assessed by MDS #6, revealed a Brief Interview for Mental Status (BIMS) score 15 of 15 which indicated he/she was cognitively intact. A nurses note dated 10/27/2024 at 05:21 PM entered by a Registered Nurse indicated that in report from the transferring hospital RI #286 had tested positive for methamphetamines, amphetamines, and meth. Further the hospital reported RI #286 had visitors bring illegal drugs to the hospital. On 05/31/2024 at 11:01 AM an interview was conducted with the SSD who indicated that she was responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and a review of the Facility Assessment, the facility failed to ensure the facility assessed addressed substance abuse, smoking and vaping. The facility's most current Facility assessment dated [DATE] did not identify the need for staff competencies regarding substance abuse. This deficient practice had the potential to affect 86 of 86 residents. These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176. Findings include: RI #286 was admitted to the facility on [DATE]. RI #286 had diagnoses that included Paraplegia, Muscle weakness, and Stimulant Dependence. RI #286 admission Minimum Data Set (MDS) dated [DATE] assessed by MDS #6, revealed a Brief Interview for Mental Status (BIMS) score 15. RI #286's medical records included Highlands Medical Center Hospitalist H&P with an admission date of 09/30/2023. The past medical history included a social history of current everyday smoker and smoked ten cigarettes per day. The level…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, residents' medical records, and the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manuals, the facility failed to ensure Section J of Resident Identifier (RI) #80 and RI #286's admission Minimum Data Set (MDS) assessments were accurately coded to reflect tobacco use during the assessment period. This had the potential to affect two of 20 sampled residents whose MDS assessments were reviewed. Findings include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019 Section J documented Section J1300: Current Tobacco Use . Coding Instructions . Code 1, yes if the resident has used tobacco since the last assessment . RI #80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Difficulty in Walking, Muscle Weakness, Lack of Coordination, and Chronic Obstructive Pulmonary Disease. A review of RI #80's Smoking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and a facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #67's nebulizer mask was stored in a covered plastic bag on 05/29/2024 and 05/30/2024. This deficient practice affected RI #67 one resident sampled for respiratory care. Finding Include: A review of a facility policy titled, Oxygen Administration with an effective date of 05/2024 revealed: Policy: Oxygen is administered to resident who need it, consistent with professional standards of practice .Policy Explanation and Compliance Guidelines: 5 .d. Keep .devices covered in plastic bag when not in use . RI #67 was admitted to the facility on [DATE] with a diagnosis of Hypertensive Heart Disease with Heart Failure. RI #67's Physician Orders for May 2024 revealed: IPRAT-ALBUT (Ipratropium-Albuterol) 0.5-3(2.5) MG (milgrams)/3 ML (milliliters) GIVE 1 VIAL PER NEB( nebublizer) EVERY 6 HOURS AS NEEDED FOR SOB (shortness of breath)/COUGH . On 05/29/2024 at 9:02 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the United States (U.S.) Food and Drug Administration, FDA Drug Safety Communication, and review of the facility policy titled Medication Administration, the facility failed to ensure a Certified Nursing Assistant (CNA) #19 did not administer her personal prescription of Klonopin 0.5 milligram (mg) to Resident Identifier (RI) #286. This deficient practice was cited as a result of the investigation of a Facility Reported Incident AL00047176. Findings include: On 03/06/2024 the State Survey Agency received a Facility Reported Incident which alleged CNA #18 was aware and did not report CNA #19 administered a Klonopin 0.5mg to RI #286. A review of the U.S. FDA FDA Drug Safety Communication dated 09/23/2020 revealed: . To address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions, the U.S. FDA is requiring the Boxed Warning be updated for all benzodiazepine medicines. Benzodiazepines are widely used to treat many conditions,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, a review of the 2017 FOOD CODE, and the facility policy titled: Low Temperature Dishmachine, the facility failed to ensure the water temperatures reached a minimum required wash water temperature of 120 to 125 degrees F during ten of eleven cycles observed. This had the potential to affect all 83 residents for whom food was prepared and served at the time of this survey. Findings Included: The 2017 Food and Drug Administration Food Code, regulation 4-501.110(B) Mechanical Warewashing Equipment, Wash Solution Temperature mandates the following: The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than . 120 degrees F (Fahrenheit). The facility policy titled: Low Temperature Dishmachine (undated) states: Dishes, glassware, cups, utensils, and other dishware are washed, rinsed, and sanitized after each use. The dish machine for ware washing will be checked prior to each meal period to ensure that it is functioning properly. All dishware will be washed and sanitized after every use. The procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility's policy titled, Perineal Care, the facility failed to ensure nursing staff cleaned front to back while providing perineal care to Resident Identifier (RI) #24. This affected one of one sampled resident observed during incontinence care. Findings Include: A review of the facility's policy titled, Perineal Care with a Review/Revision Date of 5/10/18 revealed; . PURPOSE: To maintain cleanliness, promote comfort, prevent infections and skin breakdown . I. Policy Perineal care will be provided daily and as indicated. III. Procedure for female: . K. Using a washcloth with perineal cleanser or soap and water, separate labia using one hand and bathe with the other hand using gentle downward swipes from front to back. RI #24 was admitted to the facility on [DATE] with diagnoses to include Intellectual Disabilities and Brain Damage due to Birth Injury. On 8/29/19 at 8:30 a.m., EI #1, a Certified Nursing Assistant (CNA), was observed wiping back to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review. and a review of the facility's policy titled, Hand Hygiene, the facility failed to ensure nursing staff washed her hands; 1. Before and after touching the resident, 2. before putting on and taking off gloves, 3. before leaving the resident's room to get more supplies, 4. after cleaning the perineum and before touching clean items and items in the resident's room while performing incontinence care on Resident Identifier (RI) #24. This affected one of one resident's observed for incontinence care. A review of the facility's policy titled, Hand Hygiene, with a Revision Date of 03/2018, revealed: . PURPOSE: Proper hand hygiene will improve the health of healthcare workers, patients, volunteers and visitors by decreasing the transmission of infectious agents. POLICY: . 3. Perform hand hygiene: a. before and after direct contact with patients; b. after removing gloves; . d. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to: 1. assure the facility followed correct manual dishwashing procedures per chemical distributors technical data sheet (i.e. chemical concentration in the manual dishwashing was effective by testing/documenting the water temperature in the final rinse sink when using the chemical Quaternary Ammonia). 2. assure hot foods were maintained at 135 degrees Fahrenheit (F) or above when served from the tray line as evidenced by documentation. 3. assure food (ice cream) received frozen, was maintained frozen during storage, 4. assure the PM [NAME] practiced proper handwashing/glove change when going from touching potentially contaminated objects such as (soiled cloth hot pad, equipment (lid cover of hot plate storage, on/off dial of range top and lid covers from dry storage). 5. The facility further failed to ensure a Certified Nursing Assistant (CNA) did not touch the end of Resident Identifier (RI) #13 and RI # 54's straws when setting up trays in the dining room on 07/24/18. This affected RI #13 and RI #54, two residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of a facility policy titled, Medication Administration, the facility failed to ensure a licensed nurse checked placement of Resident Identifier (RI) #11's gastrostomy tube prior to medication administration. This affected RI #11, one of one residents observed for medication administration observation via gastrostomy tube. Findings Include: A review of a facility policy titled, Medication Administration with a Last Revised date of 03/2016, revealed: .7. MEDICATION GIVEN THROUGH FEEDING TUBE A. Licensed nurses will administer per gastric tube as ordered by physician .vii. Check for proper tube placement . RI #11 was readmitted to the facility on [DATE], with diagnoses including Encounter for Attention to Gastrostomy and Diaphragmatic Hernia Without Obstruction or Gangrene. On 07/25/18 at 4:00 p.m., Employee Identifier (EI) #4, Registered Nurse (RN) was observed during medication pass administration for RI #11. EI #4 was observed not to check placement of RI #11's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure a licensed nurse did not place a bag containing a soiled brief and gloves and a bag containing soiled linens on a fall mat beside Resident Identifier (RI) #59's bed. This affected RI #59, one of one residents observed for incontinence care. Findings Include: RI #59 was readmitted to the facility on [DATE], with diagnoses including Unspecified Quadriplegia. On 07/26/18 at 8:48 a.m., during incontinence care observation, Employee Identifier (EI) #4, Registered Nurse (RN), was observed placing a bag containing soiled linen and a bag containing a soiled brief, wipes and gloves on the fall mat beside RI #59's bed. On 07/26/18 at 12:44 p.m., an interview was conducted with EI #2, RN/Staff Development/Infection Control Coordinator. EI #2 was asked, should garbage bags containing soiled linen and soiled briefs and gloves be placed on the fall mat beside the bed on the floor. EI #2 said, no. EI #2 was asked what was the concern with those items being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.