Preferred Care at Cumberland

Inspectors wroteBased on interviews and review of facility documentation on 6/10/26 and 6/15/26, it was determined that the facility failed to maintain a resident's medical information confidential in accordance with standards. This deficient practice was identified for 1 of 7 residents reviewed (Resident #7), and was evidenced by the following:a.) A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: acute osteomyelitis, type II diabetes, and memory deficit following cerebral infarction. A review of facility documented grievance records revealed a grievance dated 5/13/26 for Resident #1, which was completed by the Licensed Nursing Home Administrator (LNHA) following a phone notification by third party provider. The grievance revealed that another resident's AR was sent with Resident #1's medical information. b. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 128 of 132 residents who received dietary services.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that one (Resident (R) 13) out of four residents reviewed for Minimum Data Set (MDS) assessments was transmitted in a timely manner, out of a sample of 32 residents. This had the potential for the resident's progress not to be monitored and potential for decline.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the baseline care plan included sufficient information to provide person-centered care for one of three sampled residents (Resident (R) 161) reviewed for new admission in a total sample of 32 residents. This failure had the potential for the resident to have unmet care needs.

Inspectors wroteBased on record review, activity calendar review, interview, and observation the facility failed to ensure activities were provided in accordance with the resident's preferences for one of two sampled residents (Residents (R) 98) reviewed for activities in a total sample of 32 residents. This failure had the potential for the resident to have a diminished quality of life.

Inspectors wroteBased on record review, Functional Maintenance Program documentation review, and interview, the facility failed to ensure recommendations for passive range of motion (ROM) were implemented for one sampled resident (Residents (R) 98) reviewed for limitation in ROM in a total sample of 32 residents. This failure had the potential for the resident to experience a decline in ROM.

Inspectors wroteComplaint #: NJ175824 Based on interviews, medical record review, and review of other pertinent facility documents on 08/19/2024, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and follow the Certified Nursing Aide (CNA) job description and follow its policy titled Documentation in Medical Record for 1 of 3 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to Other Forms of Acute Ischemic Heart Disease, and Pressure Ulcer of Sacral Region Stage 2. [...]

Inspectors wroteNJ # 156264 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a clean environment in the second and third floor shower room. The deficient practice was identified on 2 of 3 shower rooms (Second & third floor) under the Environmental Task. The deficient practice was evidenced by the following: On 02/16/2024 at 11:14 AM, the surveyor entered and observed the shower room located on the second floor. At that time, the surveyor observed uncapped, opened bottles of shampoo and aftershave, discoloration on the shower floor, and white shower tiles with stains orange in appearance. The shower room also contained personal clothing draped on a shower chair, and a pair of black shoes left on the ground. Further, the surveyor observed a black, vegetative substance on the shower walls. [...]

Inspectors wroteBased on observation, interview, record review and other facility documentation, it was determined the facility failed to ensure there was a Physician's Orders (PO) for 1 of 1 residents (Resident # 471) reviewed for Respiratory Care. This deficient practice was evidenced by the following: On 2/14/24 at 11:48 AM during initial tour the surveyor observed Resident # 471 in bed with a nasal cannula (tubing that delivers oxygen to a person) applied to his/her nose with oxygen being administered at two liters per minutes. At that time, Resident # 471 said that he/she always wears oxygen. A review of Resident # 471's admission Record revealed he/she was admitted to the facility with diagnoses including but not limited to, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, and Chronic Pulmonary Edema. [...]

Inspectors wroteNJ #154489 Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed through 04/24/2022 through 05/07/2022. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 04/24/2022 through 04/30/2022 and 05/01/2022 through 05/07/2022 revealed the facility had no RN coverage for all shifts on 04/30/2022 and 05/01/2022. A review of the facility provided document titled, Time Card Report with a date range of 04/30/2022 through 05/03/2022 did not reveal any hours covered by an RN for 04/30/2022 and 05/01/2022. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow appropriate standards of practice for, a. the storage of medications at proper temperatures and b. accountability of a narcotic count sheet. This deficient practice was observed in 1 of 2 medication rooms and 1 of 3 medication carts inspected for storage and labeling and was evidenced by the following: a. On 2/16/24 at 12:16 PM, the surveyor observed the first-floor medication room for storage and labeling in the presence of Licensed Practical Nurse #2(LPN#2). Upon opening the refrigerator, the surveyor observed that the thermometer reflected a temperature of 60 degrees Fahrenheit (60F.) The surveyor also observed a clear liquid which appeared to be melted ice on the lowest shelf in the refrigerator. [...]

Inspectors wroteComplaint # NJ00158190 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure palatable temperature of food and beverage for 1 of 1 lunch meal served on 1 of 3 units (First Floor). This deficient practice was evidenced by the following: On 02/20/24 at 10:34 AM, the surveyor conducted a meeting with Resident Council which included five residents (Residents #23, #32, #54, #59, and #69). All five residents informed the surveyor that the breakfast meal was always served cold and warm food was cold and cold food was hot on all three nursing units. On 02/21/24 at 11:30 AM, the surveyor observed the Supervising [NAME] (SC) as she obtained food temperatures from the steam table. The surveyor observed that the SC did not document the food temperatures that she obtained. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to implement appropriate use of personal protective equipment, specifically by staff not wearing a gown while inside a resident room under transmission-based precautions. The deficient practice was identified for 1 of 6 residents (Resident # 470) reviewed under the Infection Control facility task. The deficient practice was evidenced by the following: On 02/15/2024 at 12:00 PM on the second floor, the surveyor observed a Certified Nurses Aide (CNA) # 1 enter a resident (Resident # 470) room with a sign on the door that revealed, USE STANDARD PRECAUTIONS PLUS + ENTERIC CONTACT ISOLATION Prior to Entering the Room. The sign revealed a illustration of a gown along with gloves. CNA # 1 entered the room with a tray of food. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that corridors were equipped with firmly secured handrails on each side. The deficient practice was identified on 1 corridor (Second Floor) and evidenced by the following: On 02/14/2024 at approximately 09:28 AM, a request was made to the Director of Maintenance (DOM) to provide a copy of the facility lay-out which identifies the various rooms, common areas and smoke compartments in the facility. A review of the facility lay-out identified the facility is a three-story (3) building with 91 Resident sleeping rooms and common areas where Residents and Visitors could go. Starting at approximately 10:10 AM on 02/14/2024 and continued on 02/15/2024 in the presence of the facility Director of Maintenance (DOM) an inspection of the building was conducted. [...]

Inspectors wroteNJ # 154489 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer, specifically by leaving the Treatment Administration Record blank on specific dates and times. The deficient practice was identified for 1 of 4 residents (Resident # 222) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 222's Significant Change Minimum Data Set (MDS; an assessment tool) dated 01/02/2023 and the Quarterly MDS dated [DATE] revealed that he/she had one stage four ulcer (severe tissue damage). A review of Resident # 222's admission Record revealed a diagnosis of but not limited to, Pressure Ulcer of Sacral Region, Stage 2. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster container area free of garbage and debris. This deficient practice was evidenced by the following: On 11/04/2021 at 10:26 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's designated trash disposal area. The surveyor observed two trash compactor units (closed units) on a cement slab. On the ground surrounding the trash compactor unit, the surveyor observed the area littered with used gloves, crates, clear plastic bags, Styrofoam and plastic cups, cooked food, leaves, sticks, plastic utensils and other unidentifiable debris. When interviewed, the FSD stated that housekeeping was responsible for cleaning the trash area. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 1 residents (Resident #104) reviewed for hospice and was evidenced by the following: During the initial tour of the 3rd floor on 11/04/21 at 10:11 AM, Resident #104 was observed lying in bed, awake, alert and wearing oxygen via nasal cannula. According to the admission Record, Resident #104 was admitted with diagnoses, that included but were not limited to, Pneumonia due to SARS- Associated Coronavirus, COVID-19, and Mild-Protein Malnutrition. Review of the Order Summary Report (OSR), for Active Orders as of 06/21/21, revealed an order for a Hospice Consult dated 06/21/21. [...]