Care and Rehab - Cumberland

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R32) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R32 was at risk for PI development. The facility failed to provide adequate and consistent wound care treatments, did not complete comprehensive weekly assessment, and did not notify provider of new PI.

Inspectors wroteBased on record review and interview, the facility must ensure each resident is free from unnecessary medications as evidenced by completing adequate behavioral monitoring for 2 of 5 residents (R7 and R16) reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility did not provide the proper discharge documentation for 2 of 2 residents (R44 and R4) reviewed for discharge. Facility did not have bed hold or notice of transfer documentation for R44. Facility did not have Ombudsman notification and notice of transfer documentation for R4.

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R1, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 1 resident (R) reviewed (R1).

Inspectors wroteBased on interview and record review, the facility did not develop and implement a person-centered care plan for a resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 1 of 5 residents (R5). R5 did not have a comprehensive person-centered care plan for the use of a high-risk medications of Apixaban, which is an anticoagulant, Furosemide, which is a diuretic, and Lantus subcutaneous solution, which is an insulin.

Inspectors wroteBased on interview and record review, the facility did not ensure care plan was revised to reflect resident's current needs and direct staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R5). R5 had changes in mood and increased depression. R5's care plan was not updated to reflect changes identified, interventions, and monitoring of R5.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R32) of 1 resident reviewed receiving physical therapy received the care necessary to meet professional standards. Facility did not obtain a Cam boot for R32's transfers as ordered from Orthopedic Surgeon I.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 1 of 1 resident (R) reviewed for falls, (R16). The facility staff did not ensure R16 had dycem pad while R16 was sitting in recliner as care planned.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection, for 2 out of 13 residents (R) (R2 and R4) reviewed. R2 and R4 have indwelling medical devices and were not on Enhanced Barrier Precautions (EBP). Licensed Practical Nurse (LPN) H did not perform hand hygiene during water flush for R4's peg tube.

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) which must include, at a minimum, an antibiotic stewardship program with a system to monitor antibiotic use. This had the potential to affect 1 of 5 residents (R7) reviewed for unnecessary medications. Hospice placed R7 on Cephalexin 500mg oral to be given two times a day for a UTI, which was not diagnosed with a urinalysis (U/A) and a culture and sensitivity (C & S). Facility did not ensure the antibiotic stewardship program was followed and that the criteria used to identify infection, McGeer's, was followed.

Inspectors wroteBased upon interview and policy review, the facility did not ensure a thorough investigation for 1 of 1 (R1) resident reviewed for safety concerns. R1 fell during an assist of 1 transfer with Certified Nursing Assistant (CNA) C without proper safety measures in place. Facility did not complete a thorough investigation when they did not interview or investigate for potential risk to other residents throughout the facility. This is evidenced by:The facility's policy and procedure for Abuse Prevention, last reviewed 05/2025, includes, in part: .The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure controlled medications were administered under professional standards of clinical practices for residents (R1, R2, R3, R4, and R5). R1, R2, R3, and R4 had narcotic medications, in which the facility did not ensure accurate documentation on the narcotic sheets. R5 has Lorazepam, which is a controlled substance, needing a double lock. The medication was not double locked.

Inspectors wroteBased on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with professional standards of practice. The facility did not ensure that a Registered Nurse (RN) assessed a resident after a fall occurred. This had the potential to effect 2 of 7 residents (R) (R29, R193) investigated for accidents.

Inspectors wroteBased on interview and record review, the facility did not ensure new care planned fall interventions were implemented post falls to prevent accidents for 1 of 7 residents (R) R29, reviewed for falls. The facility did not implement fall interventions or identify root cause for ten fall incidents, of which R29 sustained minor injury.

Inspectors wroteBased on interview and record review, the facility did not have documentation included in resident's medical record that the residents and/or the resident's responsible party received education regarding the benefits and potential side effects of the influenza vaccine, and the resident (R), either received the influenza immunization or did not receive the influenza immunization for 3 out 5 (R3, R13, R15) residents sampled. R3, R13, and R15 did not have declinations on file, nor was there documentation stating these residents or their representatives refused the vaccine and were educated on the benefits of receiving the influenza vaccine.

Inspectors wroteBased on observations and interviews, the facility did not ensure personal privacy for 2 of 4 residents (R2 and R28) during personal cares and medical treatment. R2 and R28's curtains were not shut during cares and medical treatment to ensure personal privacy. This is evidenced by: The facility policy, entitled Privacy/Dignity, dated 03/2023 states in part Resident's privacy and dignity is maintained at all times and by all staff during all cares and interactions. On 09/07/23 at 9:55 AM, Surveyor asked R2 if it was ok for Surveyor to watch staff transfer R2 into bed. R2 indicated privacy doesn't matter here. Surveyor observed Certified Nursing Assistants (CNA) M and N lower R2 into bed. CNAs removed R2 shoes, then pulled down R2's pants, and opened up incontinent product to change resident all while the curtain was open. [...]

Inspectors wroteBased upon interview, record review and policy review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 of 2 residents (R) (R22, R32) reviewed. R22 alleged she had lost clothing and did not know what had happened to the clothing. The facility did not complete a thorough investigation of the incident. R32's Power of Attorney (POA) said that R32 had lost a stuffed animal and was mentioned to staff but never knew what came of the complaint. The facility did not complete a thorough investigation of the incident. This is evidenced by: On 09/05/23 at 10:27 AM, Surveyor interviewed R22 regarding lost or stolen items. R22 said they had lost some clothing and had mentioned it to staff, and they were unsure how long the clothing had been missing. R22 was unsure what had happened and did not know if she had ever seen the clothing again. [...]

Inspectors wroteBased on interviews and record review, the facility did not complete and implement baseline or comprehensive care plans for 1 of 12 residents (R245) within 48 hours of admission, which included instructions on how to provide effective and person-centered care for the resident. No baseline care plan was developed within 48 hours to address the minimum healthcare information necessary to properly care for R245, including, but not limited to, such areas of catheter care, weight loss, functional abilities, and the assistance R245 requires. This is evidenced by: The facility policy, entitled Comprehensive Nursing Assessment, dated April 2019, states: 1. A RN [Registered Nurse] initiates nursing assessment focus on newly admitted residents that occurred during the shift and completes a temporary care plan that serves as the interim care plan. R245 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a comprehensive care plan was achieved for 2 of 12 residents (R) reviewed for care plans (R31, R245). R31 did not have a care plan to address incontinence care. R245 did not have a care plan to address falls, nutrition, pressure injuries, and catheter care. This is evidenced by: R31 was admitted to facility on 04/13/23. Quarterly Minimum Data Set (MDS), completed and dated 07/21/23, indicated R31 was occasionally incontinent. R31 was coded to require supervision for toileting and extensive assist personal hygiene. R31's Activities of Daily Living (ADL) care plan states . set up and wash own peri care. A care plan was not developed for urinary incontinence and assistance with personal hygiene. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not review and revise the comprehensive care plans for 1 of 12 sampled residents (R), R28. R28's care plan was not updated to identify the resident no longer has to be on contact precautions. This is evidenced by: On 09/05/23, Surveyor reviewed R28's care plan with a printed date of 09/07/23. It stated, Contact precautions due to MRSA + wound culture. May come out of room for meals and activities as long as wound is covered and drainage is contained. On 09/07/23 at 10:17 AM, Surveyor observed wound care being done on R28. Staff did not apply personal protective equipment (PPE) other than gloves. On 09/07/23, Surveyor interviewed Registered Nurse (RN) I and asked if R28 was on any precautions. RN I indicated R28 had history of Methicillin Resistant Staph Aureus (MRSA) but was no longer on precautions. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that the resident environment remained as free of accident hazards as possible for 2 of 5 residents (R) reviewed for room water temperature (R41, R10) and 1 of 4 residents (R245) reviewed for falls. Hot water temperatures in R41's and R10's rooms exceeded the recommended maximum temperature of 115 degrees Fahrenheit plus or minus two degrees. R245 did not have a fall assessment completed after a fall occurred. This is evidenced by Example 1 Surveyor reviewed the facility water temperatures logbook that documents the required hot water temperatures in resident rooms to be between 110 - 115 degrees Fahrenheit. On 09/06/23 at 9:55 AM, Surveyor used a thermometer to check the hot water temperature for R41's room. After 20 seconds, the hot water temperature reached 118.9 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 resident (R) of 3 residents (R31) reviewed with a change of bladder continence status received services to restore continence status. The facility did not ensure a medical rationale to justify a catheter change on a scheduled basis for 1 of 2 residents (R9) reviewed. R31 was assessed on admission as being continent of bladder. On 07/21/23, R31 was assessed as occasionally incontinent and did not receive services to restore continence status. R9's indwelling catheter was ordered to be changed on a scheduled basis without a medical rationale. This is evidenced by: Facility policy entitled Bowel and Bladder Tracking, Assessment & Evaluation dated 5/2016, which states, Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prior to the installation or use of bed rails, the facility attempted to use alternatives, ensure the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative for 3 of 3 residents (R) R14, R245, R16. The facility did not ensure the grab bars are appropriate for R14 and did not assess risk of entrapment versus benefit. The facility failed to assess R245 for risk of entrapment prior to installing bed rails. The facility did not assess R16 for risk of entrapment prior to installing bed rails. This is evidenced by: On 09/06/23 at 7:59 AM, Surveyor observed bilateral grab bars on R14's bed. [...]