Cumberland Crossings Retirement Community

In the surveyor’s words

From the most serious findings on record at Cumberland Crossings Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 23, 2022

  Based on observation, facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers, promote healing, and prevent infection resulting in development and worsening of two pressure ulcers and infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 56). Findings Include: Review of Resident 56's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880May 25, 2023

  Based on staff interviews, policy review, Centers for Disease Control guidelines, and documents reviewed for implementation of a water management program, it was determined the facility failed to implement their water management program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease [a serious type of pneumonia]). Findings include: During an interview with Employee 1 (Maintenance Technician) on May 25, 2023, at 9:00 AM, Employee 1 indicated they were not aware of a water management program and that the facility was on township water and the township completes all required testing. They further indicated that the township does testing weekly and the facility receives an annual report of findings. […]

• No harm, potential for more than minimal, patternF947Apr 10, 2025

  Based on personnel training record review and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided required in-service training, consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention for three of five nurse aide employee records reviewed (Employees 1, 2, and 3). Findings Include: Review of personnel information revealed Employee 1's hire date was October 28, 2019; Employee 2's hire date was December 5, 1994; and Employee 3's hire date was November 17, 2015. […]

• No harm, potential for more than minimal, patternF692May 25, 2023

  Based on review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration status for two of 16 residents reviewed (Resident's 6 and 24) Findings include: Review of facility policy, titled Encouraging and Restricting Fluids last revised October 2010, revealed Remove the resident's water pitcher and cup from the room .The following information should be recorded in the resident's medical record: The amount (in mLs) of fluids consumed by the resident during the shift. […]

• No harm, potential for more than minimal, patternF803May 25, 2023

  Based on observations, facility policy, select facility document review, and resident and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu for one of one meals observed (May 24, 2023, lunch meal). Findings include: Interviews with residents during the initial pool process revealed concerns with consistent food portions. Review of resident council meeting minutes revealed concern that portion size of food vary each meal and aren't consistent for three out of six months reviewed. […]