Carolina Rehab Center of Cumberland

In the surveyor’s words

From the most serious findings on record at Carolina Rehab Center of Cumberland, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 4, 2024

  Based on observation of a recorded video, record review and interviews with resident, staff, and a van transportation company, the facility failed to ensure a resident was safely transported to a physician's visit. The facility's contracted transportation company's Van Driver failed to ensure the lift platform was level with the van before rolling Resident # 7 out of the van. The resident fell backwards out of the transport van to a lift platform that was located on the ground approximately 3 feet below the level of the van. Review of the van company's recorded video of the incident revealed the resident could be heard crying and yelling loudly when she hit the ground. […]

• Immediate jeopardy, isolatedF600Mar 25, 2024

  Based on observation, record review, and interviews with staff, family, residents, the physician and the facility's psychiatric provider, the facility failed to protect a cognitively impaired and dependent resident (Resident # 3) from abuse by another cognitively impaired resident (Resident # 2). Resident # 2 was known by staff to display behaviors which included paranoia, delusions, aggression with staff, and exit seeking behaviors. Resident # 2 entered Resident # 3's room while staff were attending to other residents during an evening meal and assaulted Resident # 3 by pulling Resident # 3's wheelchair over on the floor resulting in Resident # 3 landing on the floor; hitting and kicking Resident # 3 in the head; beating Resident # 3 with a meal tray and; hitting Resident # 3 with the… […]

• Immediate jeopardy, isolatedF689Jun 11, 2021

  Based on record review, observation and staff interviews, the facility failed to supervise and monitor a resident who was not compliant with the smoking policy and was found smoking in room with oxygen via nasal cannula on three occasions for one of five sampled residents (Resident #87) reviewed for smoking compliance. There was also no system or interventions in place to prevent recurrent noncompliance with the smoking policy by residents. The immediate jeopardy (IJ) began on 10/1/20 when Resident # 87 was found to be smoking in his room with oxygen present and no effective interventions were implemented to prevent reoccurrence. Immediate Jeopardy was removed 6/9/21 when the facility submitted an acceptable credible allegation of immediate jeopardy removal. […]

• Actual harm, isolatedF684Mar 5, 2025

  Based on record review, and staff, Wound Care Nurse Practitioner and Podiatrist interviews, the facility failed to obtain orders to coordinate care with the resident's Podiatrist to ensure care needs were met when a resident was admitted with no orders regarding care to a surgical incision site of the right heel. The surgical dressing was not removed, and no treatment was provided. At the Podiatrist visit on 1/13/25 the wound was significantly macerated (skin had become soft and broken down due to prolonged moisture) that had extended laterally out of the incision. Podiatrist #1 saw Resident #4 on 1/13/25 and started oral antibiotics and treatment orders to the incision site. Podiatrist #2 saw Resident #4 on 1/15/25 and changed the treatment orders to the incision site. […]

• Actual harm, isolatedF689May 3, 2024

  Based on record review, staff and physician interviews, the facility failed to provide care safely to a dependent resident (Resident #216) when the resident sustained a facial fracture when her face hit the bed side rail during care for 1 of 5 residents reviewed for accidents. Findings included: Resident #216 was admitted to the facility on [DATE] with diagnoses which included cerebral infarct and vascular dementia. The quarterly Minimum Data Set, dated dated dated [DATE] indicated that she had severely impaired cognition and was dependent on staff for all activities of daily living (ADL). […]