Cumberland Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure they reported allegations of abuse to law enforcement and to the state survey agency within two hours, which affected 1 (Resident 94) of 3 residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prohibition Standard of Practice, last reviewed 03/2026, revealed, the Purpose was To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State laws. The policy further indicated, 7. Reporting/Response included Alleged violation/violations will be reported to the Administrator and or designee immediately; Alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies (e.g. [exempli gratia; for example], law…

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 facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate allegations of abuse, including misappropriation of property, for 2 (Resident 31 and Resident 94) of 3 residents reviewed for abuse. Findings included: A facility policy titled, Abuse Prohibition Standard of Practice, last reviewed 03/2026, indicated the Purpose was To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State laws. The policy further indicated, 5. Investigation included If an actual or alleged violation occurs, the resident will immediately be assessed and removed from any potential harm (as applicable); The administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect,…

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 observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping services to ensure a clean and sanitary environment for four (Resident (R) 6, R7, R64, and R37) of 21 sampled residents. Each of these resident rooms, as well as all four of four shower rooms used by residents, were noted to need cleaning, with a black, fuzzy-appearing substance (which had a strong odor), growing around sinks, in bathrooms, on tiles, and high moisture areas. The findings include: Review of the undated facility policy titled, Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment. A policy for housekeeping titled Housekeeping Daily Duties, dated 12/2001, revealed a schedule of what housekeeping would do on each day of the week. The policy states All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur. 1. Observation during a tour of the A, B, C, and D-Hall shower rooms on 04/23/2025 revealed that all four shower rooms had a…

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 observation, interview, record review, and policy review, the facility failed to ensure that two of four corridors were equipped with firmly secured handrails on each side of the hallway. Failure to have firmly secured handrails could affect residents' ability to safely ambulate down the hallways. The findings include: Review of an undated facility policy titled Resident Rights, revealed residents have a right to a safe environment. No specific policies related to maintenance or inspection of handrails were provided during the survey. Observation during a tour of the A and B Halls on 04/22/2025, initiated at 11:46 AM, revealed the following: 1. The handrail outside of resident room A7 was loose and shifted when light pressure was applied. 2. A corner joint was missing from the handrail outside of resident room A8 with a blunt end exposed. 3. The handrail outside of resident room A10 was missing screws that connected it to the support brackets, allowing the handrail to be easily moved when pressure was applied. 4. The handrail outside of resident room B2 did not have screws…

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, record review, and facility policy review, it was determined the facility failed to ensure that one resident (Resident (R) 6), who was unable to carry out activities of daily living (ADLs), out of a total sample of 21 sampled residents, received the necessary services to maintain good grooming and personal hygiene. R6 failed to receive nail care as needed, and was noted with long, dirty nails on multiple occasions. The findings include: Review of the facility policy Activities of Daily Living Tasks, dated 01/012001, revealed, Any resident that has a deficit that keeps them from doing any kind of ADL's will be helped with whatever need they have. Per the policy, Nails should be observed daily and cut when appropriate. Review of the electronic medical record revealed R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and cerebrovascular accident (CVA) with left-sided weakness. Review of R6's Annual Minimum Data Set (MDS) with an Assessment…

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 interview and record review, it was determined the facility failed to conduct a comprehensive annual assessment within the required timeframe for one (1) of twenty-two (22) sampled residents (Resident #1). A review of Resident #1's Minimum Date Set (MDS) assessments revealed the resident had not had an annual assessment completed in March 2021, as required. The findings include: Interview with the Director of Nursing (DON), on 07/16/2021 at 2:58 PM, revealed the facility did not have a policy for completing the Minimum Data Set (MDS) assessments, but stated the facility followed the Resident Assessment Instrument (RAI) process to complete the assessments. A review of the Long-Term Care Facility Resident Assessment Instrument version 3.0 User's Manual, revealed the annual assessment was a comprehensive assessment for a resident that the facility must complete on an annual basis. Review of Resident #1's medical record revealed the facility admitted the resident on 06/07/2020, with diagnoses including Multiple Sclerosis, Bladder Disorders, Atrial Fibrillation, and Esophageal…

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, interview, and review of facility policy, it was determined the facility failed to ensure all mechanical equipment was in safe operating condition. Observation in the dish room revealed a pan underneath the dishwasher sink was full of water. Interviews revealed during the night when the kitchen was closed water overflowed into the kitchen and storage room. The findings include: Review of the facility Equipment policy, revised September 2017, revealed all food service equipment would be clean, sanitary, and in proper working condition. Observation at 3:20 PM on 07/18/19 revealed a large plastic pan sitting on the floor underneath the sink that was connected to the dishwasher. The pan contained two to three gallons of water. The water was coming from a constant leak from a copper fitting underneath the scrapping sink that was connected to the dishwasher. Interview with Dietary Employee #1 at 4:30 PM on 07/18/19 revealed when she entered the kitchen at 5:00 AM each morning, the pan underneath the dishwasher/sink had overflowed onto the floor. The employee stated…

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 observation and interview, it was determined that the facility failed to maintain a safe, clean, homelike environment for residents who utilized one (1) of seven (7) bathrooms on the A Hall. Observation on 07/17/19 and 07/18/19, revealed a bedpan, fracture bedpan, and an emesis basin were lying on the bathroom floor in the bathroom for rooms A1 and A3. The items were being stored in a stack, uncovered, and not labeled with a resident name. The findings include: An interview with the Director of Nursing (DON) on 07/19/19 at 9:00 AM, revealed the facility did not have a policy for storage of reusable resident equipment such as bedpans and basins. However, an interview with the Wound Care/Infection Control Nurse on 07/19/19 at 2:11 PM, revealed reusable resident supplies should be stored in plastic bags and labeled with the resident's name. Observation of the bathroom located between resident rooms A1 and A3 on 07/17/19 at 11:07 AM, revealed a bedpan with a fracture bedpan and an emesis basin placed inside it, lying on the floor beside the toilet. The items were not in a…

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, and record review, it was determined that the facility failed to provide treatment and services to prevent urinary tract infection for one (1) of nineteen (19) sampled residents (Resident #66). Observations on 7/16/19 and 7/17/19 revealed Resident #66's catheter bag was touching and/or dragging the floor while hanging beneath the resident's wheelchair. The findings include: The Administrator stated on 07/18/19 at 1:04 PM, that the facility did not have a policy regarding indwelling urinary catheter care. However, interview with the Director of Nursing (DON) on 07/18/19 at 3:18 PM, revealed her expectation was that a urinary catheter drainage bag should not touch the floor. Review of Resident #66's medical record revealed the facility admitted the resident on 06/14/18 with diagnoses of Hypertension, Benign Prostatic Hypertrophy with Lower Urinary Tract Symptoms, Thrombocytopenia, Spinal Stenosis, and Difficulty Walking. Review of Resident #66's quarterly Minimum Data Set (MDS)…

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, record review, and interview, it was determined that the facility failed to ensure that the administration of enteral nutrition was consistent with physician orders for one (1) of nineteen (19) sampled residents (Resident #187). Resident #187 had a physician's order to increase tube feeding by 10 cubic centimeters (cc) every 72 hours until 65 cc per hour were being administered. However, observation and record review revealed the facility failed to increase the resident's tube feeding as ordered. The findings include: Interview with the Director of Nursing on 07/18/19 at 3:20 PM revealed the facility did not have a policy for tube feedings. Review of Resident #187's medical record revealed the facility admitted the resident on 06/27/19 and discharged the resident to an acute hospital on [DATE]. The resident had diagnoses that included Debility, Cardiorespiratory conditions, Dysphagia, Anemia, Hypertension, Urinary Tract Infection, Parkinson's disease, Healed Traumatic Fracture, Chronic…

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.