Cumberland Pointe Care Center

Inspectors wroteBased on record review, including review of facility billing/financial information, interview, and review of the Administrator Job Description, the facility failed to be administered in a manner to prevent potential interruption in service or delay in receipt of inspection reports as a result of not following up timely to failed generator testing. This had the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure dignity was maintained related to urinary catheter drainage bags and mealtime. This affected two residents (Resident #2 and #70) of three residents reviewed for dignity. The facility census was 66.

Inspectors wroteBased on medical record review, observations, and interviews the facility failed to ensure orders for restorative therapy were implemented timely. This affected one (Resident #12) of five residents reviewed for positioning. The facility census was 66.

Inspectors wroteBased on medical record review, review of fall incident report, interview, observation the facility failed to ensure fall interventions were in place per plan of care and failed to ensure in use wheelchairs were maintained without cracks, tears and exposed padding. This affected two residents (Resident #5 and #8) of three residents reviewed for accidents. The facility census was 66.

Inspectors wroteBased on medical record review, review of resident counsel minutes, observation, interviews, and policy review the facility failed to ensure residents received adequate hydration and changes in nutritional status were addressed timely. This affected two (Resident #9 and #12) of two reviewed for hydration and two (Resident #12 and #38) of eight reviewed for nutrition. The facility census was 66.

Inspectors wroteBased on observation, interview, review of manufacture guidelines, and policy review the facility failed to provide post-inhaler care per guidelines to prevent potential complications due to use. This affected one resident (Resident #22) of two residents observed for medication administration. The facility census was 66. Findings Include: Review of the medical record for Resident #22 revealed an initial admission date of 06/29/18 with diagnosis including tumor of kidney, lung disease, heart failure, stroke, difficulty swallowing, weakness, moderate intellectual disability, epilepsy, high blood pressure, and depression. Review of Resident #22 physician order summary for September 2025 revealed an order for QVAR Redihaler 80 micrograms (mcg) inhale one puff twice a day. On 09/09/25 at 7:55 A.M. [...]

Inspectors wroteBased on staff observation, record review, staff interviews, and policy review the facility failed to prepare and administer medications in a sanitary manner for Resident #55. This affected one (Resident #55) of two residents observed for medication administration. The facility census was 66.

Inspectors wroteBased on review of the medical record, review of the facility menus, review of incident logs, resident interviews and staff interviews, the facility failed to ensure Resident #47 #53, and #57 were able to make meal choices which aligned with their preferences. This affected three residents (Resident #47, #53, #57) of five reviewed for residents rights with meal preferences.

Inspectors wroteBased on review of the facility Payroll Based Journal (PBJ) submission data for the third quarter of 2024, review of the facility assessment, review of medical records, review of shower sheets, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected five residents (#16 , #25, #27, #31, and #52) and had the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on review of the criminal background check log, interview, and policy review, the facility failed to ensure all staff had a completed criminal background check. This had the potential to affect all 65 residents.

Inspectors wroteBased on review of the facility Payroll Based Journal (PBJ) submission data for the first quarter of 2024, review of the facility assessment, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected six residents (#46, #44, #2, #39, #28 and #51) and had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observations, review of personnel records, policy review, review of time punches, and interview, the facility failed to ensure staff were adequately tested for signs of tuberculosis prior to resident contact and failed to maintain infection control protocols during medication administration and incontinence care. This affected Residents #10 and #15 and had the potential to affect all 65 residents.

Inspectors wroteBased on review of documents from the facility's food supplier and interview, the facility failed to ensure provisions were made to have water available in the event of an emergency. This had the potential to affect all 65 residents.

Inspectors wroteBased on observation, facility worksheet review, interviews and policy review the facility failed to ensure medication was properly secured and accessible only to authorized staff and failed to ensure insulin was dated upon opening and/or discarded after expiration. This affected five residents receiving insulin (Resident #23, #26, #29, #50, #63) but had the potential to affect all residents residing in the facility. The facility census was 65.

Inspectors wroteBased on review of a facility investigation, review of personnel files, medical record review and interview, the facility failed to ensure all residents were treated with dignity and respect. This affected one (Resident #36) of five residents reviewed for dignity. The facility census was 65.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure resident rooms on the secure unit were clean, safe, and a homelike environment was maintained. This affected three residents (#47, #53, and #60) of six residents observed on the secure unit during the initial survey process. The census was 65.

Inspectors wroteBased on record review, review of missing item reports, review of dental appointment visit lists, family interview, staff interview, and policy review, the facility failed to ensure a resident and her resident representative's concerns of missing dentures were addressed by the facility. This affected one (Resident #47) of two reviewed for personal property. The facility census was 65.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident had a new resident review completed after a newly diagnosed mental illness was added to their diagnoses. This affected one (Resident #5) of one residents reviewed for Preadmission Screening and Resident Review (PASRR) assessments.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents bowel movements were properly monitored and those residents who went without a bowel movement for greater than three days received appropriate intervention to promote a bowel movement to occur. This affected two (Resident #5 and #20) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, interview, and consult notes review the facility failed to ensure Resident #4 was provided orthotic devices and/or restorative exercises for decreased range of motion (ROM) to the right lower extremity. This affected one (Resident #4) of two residents reviewed for positioning. The facility census was 65.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure a resident who was at risk for falls had fall prevention interventions implemented as per her plan of care. This affected one (Resident #47) of three residents reviewed for falls. The facility census was 65.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents met criteria of antibiotic treatment. This affected one (Resident #17) of two reviewed for antibiotic stewardship. The facility census was 65.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents received the pneumococcal vaccine per recommendation. This affected one (#59) of five residents reviewed for immunizations. The facility census was 65.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents and/ or the resident representatives received written notice of the residents transfer to the hospital and the Ombudsman was notified of the residents' transfer to the hospital as required. This affected two (Resident #5 and #68) of two residents reviewed for hospitalization. The facility census was 65.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents and/ or the resident representatives received a bed hold notice when residents were transferred out to the hospital and was hospitalized as required. This affected two (Resident #5 and #68) of two residents reviewed for hospitalizations.

Inspectors wroteBased on record review and interview, facility failed to provide showers to dependent residents scheduled per resident preference. This affected one resident (#73) of three residents reviewed for extensive activity of daily living (ADL) assistance. The facility census was 61.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to maintain adequate levels of staffing to ensure all residents received necessary care and treatment, including timely bathing/showers and/or supervision to prevent elopement. This affected five residents (#35, #15, #38, #64 and #63) and had the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to properly store and/or date opened medications. This had the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National emergency dated 03/13/20, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, observation, record review, facility policy and procedure review and interview the facility failed to maintain proper infection control practices during resident care to prevent the spread of infection including COVID-19. This affected four residents (#36, #46, #117 and #218) and had the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure residents with limited range of motion (ROM) received restorative therapy to maintain function or prevent decline in ROM. This affected four residents (#4, #8, #12 and #57) of five residents reviewed for range of motion.

Inspectors wroteBased on observation, record review, review of shower schedules and interview the facility failed to ensure Resident #15, #38 and #64 were provided baths/showers according to their preference. This affected three residents (#15, #38 and #64) of 13 residents interviewed regarding their ability to make choices for bath/shower preferences.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure timely physician notification for Resident #54's related to significant weight changes and for Resident #14 related to a low blood glucose level. This affected two residents (#14 and #54) of two residents reviewed for physician notifications.

Inspectors wroteBased on record review and interview the facility failed to provide a bed hold notification to Resident #17 as required. This affected one resident (#17) of two residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview the facility failed to provide timely restorative nursing services to maintain or improve the ambulatory abilities of Resident #36 following the resident's discharge from physical therapy. This affected one resident (#36) of three residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review, review of shower schedules and interview the facility failed to ensure Resident #15, #38 and #64, who were dependent on staff for bathing were provided baths/showers according to their preference and schedule. This affected three residents (#15, #38 and #64) of 13 residents interviewed regarding their ability to make choices for bath/shower preferences.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure weight monitoring was completed as ordered for Resident #54, who had a diagnosis of congestive heart failure and failed to ensure a comprehensive and individualized bowel regimen was implemented for Resident #17 as ordered. This affected two residents (#17 and #54) of five residents reviewed for quality of care and/or nutrition.

Inspectors wroteBased on observation, record review and interview the facility failed to provide adequate supervision to Resident #63 to prevent the resident from leaving the facility unsupervised and failed to ensure fall safety interventions were in place for Resident #55 as planned to prevent injury associated with fall risk. This affected two residents (#55 and #63) of seven residents reviewed for accidents.

Inspectors wroteBased on observation, record review, review of the dietitian job description, nutrition best practice review, facility policy and procedure review and interview the facility failed to ensure the dietitian or qualified dietary employee timely assessed and addressed a significant weight gain for Resident #8. In addition, the facility failed to ensure weight changes were timely communicated to the resident's physician. This affected one resident (#8) of two residents reviewed for food choices.

Inspectors wroteBased on record review and interview the facility failed to ensure laboratory testing was obtained for Resident #57 as ordered by the physician. This affected one resident (#57) of six residents reviewed for unnecessary medication use.