Care and Rehab - Cumberland

In the surveyor’s words

From the most serious findings on record at Care and Rehab - Cumberland, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 18, 2026

  Based 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.Findings include: R32 was admitted to the facility on [DATE] with diagnoses including in part, atrial fibrillation, nonrheumatic aortic insufficiency, hypertensive heart disease, peripheral vascular disease, unilateral osteoarthritis left ankle and foot, hypertension, weakness, and presence of right artificial… […]

• No harm, potential for more than minimal, patternF755Jul 7, 2025

  Based 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. Findings include: On 07/07/25 at 12:25 PM, Surveyor observed medication cart on 200-300 hall with Registered Nurse (RN) C. Surveyor observed R1, R2, R3 and R4's narcotic sheets to have discrepancies. […]

• No harm, potential for more than minimal, isolatedF605Feb 18, 2026

  Based 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.Findings:Facility policy titled, PSYCHOTOPIC MEDICATIONS, revised 1/26, stated in part: 6. The specific targeted behaviors for which the drug is being administered will be entered by the nurse on the behavior monitoring record. The effectiveness of the psychotropic drug will be documented on the behavior sheet each shift. Total occurrences may be based on the personal observation or the observation of other staff members 8. […]

• No harm, potential for more than minimal, isolatedF628Feb 18, 2026

  Based 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.Findings:Example 1R44 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 13/15, which indicated R44 was cognitively intact. R44 had Minimum Data Set (MDS) stating 'Discharge Return Anticipated' dated on 01/14/26 and 12/21/25.On 02/18/26 at 9:13 AM, Surveyor was unable to find a bed hold for discharge date of 01/14/26 and a notice of transfer form. […]

• No harm, potential for more than minimal, isolatedF645Feb 18, 2026

  Based 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).Findings include:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. […]