Cumberland Pointe Health Campus

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was kept safe during care and was evaluated for assistive devices to prevent an accident for 1 of 1 resident reviewed for accidents. (Resident 19) This deficient practice resulted in a right femoral neck fracture, a left scalp laceration, and a hematoma of the frontal scalp for Resident 19.

Inspectors wrote2. The clinical record for Resident 29 was reviewed on 6/10/25 at 3:06 p.m. The diagnoses included, but were not limited to, diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility. A current physician's order, dated 12/22/21, indicated Resident 29 had a full code status. A care plan, dated 12/23/21, indicated advanced directives would be reviewed quarterly and honor Resident 29's medical POA's decisions. An Indiana Physicians Orders for Scope of Treatment (POST) form, dated 4/9/24, was signed by Resident 29's power of attorney (POA) and indicated the resident's code status was DNR (do not resuscitate). It was not signed by a physician. During an interview, on 6/11/25 at 10:00 a.m., Resident 29 indicated she wanted to be a DNR. [...]

Inspectors wrote2. The clinical record for Resident 29 was reviewed on 6/10/25 at 3:06 p.m. The diagnoses included, but were not limited to, diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility. A quarterly MDS assessment was completed on 2/22/25. There was no documentation in the clinical record, a care plan meeting for the quarterly assessment was completed. An annual MDS assessment was completed on 5/22/25. There was no documentation in the clinical record, a care plan meeting for the annual assessment was completed. During an interview, on 6/16/25 at 11:06 a.m., the DON indicated care plan meetings should be completed on admission and quarterly. There should have been two care planning meetings completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a blood pressure medication was administered according to the physician's orders for 1 of 1 resident reviewed for quality of care. (Resident 19)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders for the care and monitoring of a catheter were obtained upon admission for 1 of 1 resident reviewed for catheter. (Resident 104)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed the physician's orders related to a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for gastrostomy tubes. (Resident 43)

Inspectors wroteBased interview and record review, the facility failed to implement physician's orders based upon current professional standards of practice for the maintenance and prevention of infection of an Intravenous (IV) line for 1 of 1 resident reviewed for IV therapy. (Resident 101)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for oxygen was in place and oxygen equipment was stored properly when not in use for 1 of 3 residents reviewed for respiratory care. (Resident 1)

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of the residents for 1 of 3 residents reviewed for pharmacy services. This deficient practice was corrected on 1/24/25, prior to the start of the survey, and therefore was past noncompliance. (Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a bowel stimulant according to the bowel protocol, failed to ensure residents were wearing compression hose as ordered by the physician, failed to hold a medication per the physician's hold orders, and failed to ensure a preventive cushion was in place for 4 of 4 residents reviewed for quality of care. (Residents 43, 44, 15 and 25)

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) level 2 was accurately documented on the comprehensive/annual MDS (Minimum Data Set) assessment submitted for 1 of 3 residents reviewed for PASRR level 2. (Resident 34)

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) after a resident was started on an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Resident 18)

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication as ordered by the physician and failed to notify the physician when the medication was not administered for 1 of 1 resident reviewed for pain. (Resident 9)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a full meal in a timely manner, as noted on the dietary menu slip, to a resident on a gluten free diet for 1 of 1 resident reviewed for an alternate diet. (Resident 43)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive dining equipment for 1 of 3 residents reviewed for dining. (Resident 43)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were wearing hair and facial covers while in the kitchen for 3 of 3 randomly observed staff members. (Staff Member 52, [NAME] 6 and Kitchen Employee 13)

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) was professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field and was also able to dedicate at least part-time to the roll for 1 of 1 Infection Preventionist reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure frozen food was securely covered, the refrigerator did not contain employee drinks and the thermometer used to temp food was cleaned between testing temperatures. The deficient practice had the potential to affect 62 of 62 residents who received food from the kitchen.

Inspectors wrote9. The record for Resident B was reviewed on 03/01/23 at 10:25 a.m. Diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, end stage renal disease, acute embolism and thrombosis of right femoral vein, acute embolism and thrombosis of deep veins of right upper extremity, saddle embolus of pulmonary artery without acute cor pulmonale, severe protein calorie malnutrition, mitral valve insufficiency, left bundle branch block, thrombocytopenia, hypotension, and a pacemaker. During the record review, the resident received the following medications late: a. levothyroxine (a hormone supplement) was administered late on 10/2/23. b. cholecalciferol (a supplement), colchicine (an anti-inflammatory) and omeprazole (to treat heartburn) were administered late on 10/23/22. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a cognitively impaired resident had the same bed as other residents to prevent the bed frame from being on the floor for 1 of 1 resident reviewed for dignity. (Resident 59)

Inspectors wrote2. The record for Resident 51 was reviewed on 03/01/23 at 11:50 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, delirium due to known physiological condition, hallucinations, and cerebellar stroke syndrome. A physician's order, dated 12/1/22, indicated lorazepam (an antianxiety) 0.5 milligrams at bedtime. A physician's order, dated 1/23/23, indicated Depakote sprinkles (a mood stabilizer) 250 milligrams three times daily. A physician's order, dated 1/23/23, indicated Seroquel (an antipsychotic) 25 milligrams three times daily. A physician's order, dated 2/27/23, indicated lorazepam 0.5 milligrams every four hours as needed. There was no documentation in the electronic medical record regarding education of the risks of psychoactive medications with the resident or representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update the care plan to include the resident's preferred activities for 1 of 4 residents reviewed for activities (Resident 42).

Inspectors wrote2. During an observation, on 2/28/23 at 10:20 a.m., Resident F was sitting in a wheelchair. The resident's hair was not brushed and appeared dirty. During an observation, on 3/2/23 at 10:30 a.m., the resident's hair appeared flat and dirty. The record for Resident F was reviewed on 3/2/23 at 10:32 a.m. Diagnoses included, but were not limited to, anxiety disorder, transient cerebral ischemic attack, and chronic kidney disease. A profile care guide, dated 8/24/22, indicated Resident F's showers were scheduled on Tuesday and Saturday during the evening shift. The MDS (Minimum Data Set) assessment, dated 1/9/23, indicated the resident needed one-person physical assist with showers and bathing. A point of care history indicated Resident F was missing 8 showers from 12/1/22 through 2/28/23. During an interview, on 3/6/23 at 11:45 a.m., RN 5 indicated Resident F did not refuse care. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a weight on a resident who was identified as a risk for malnutrition for 1 of 3 residents reviewed for nutrition. (Resident 59)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident or representative had been instructed on the specific risks versus benefits of bed rails and to have a signed consent for 1 of 2 residents reviewed for accident hazards. (Resident 12)

Inspectors wrote2. During an observation, on 03/01/23 at 11:46 a.m., the resident was resting in the bed, on her right side, with the head of the bed elevated slightly. Her daughter was visiting in the room with an activity staff member. The resident had her eyes closed. The resident was not grimacing or restless. During an observation, on 03/01/23 at 4:05 p.m., the resident was resting in the bed, on her right side, with the head of the bed slightly elevated. The resident had her eyes closed. No restlessness or movement was observed. During an observation, on 03/02/23 at 11:01 a.m., the resident was resting comfortably in bed with a low air loss mattress in place. She was lying on her right side and her eyes were closed. The record for Resident 51 was reviewed on 03/01/23 at 11:50 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication was not left on the top of the medication cart and the medication cart was locked for 2 of 4 carts and the temperature log for the 300-hall medication room was completed for 1 of 2 medication storage rooms reviewed for medication storage. (100 and 300 halls carts and 300 hall medication room).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the cook prepared pureed foods according to the recipes for 1 of 1 resident who was ordered a pureed diet. (Cook 1)