Cumberland Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627May 28, 2026

  Based on record review and interview, it was determined that the facility failed to implement an effective discharge planning process. This was evident for 4 (#4, #8, #9, and #10) of 5 residents reviewed for discharges. On 5/21/26 at 2:05 PM, an immediate jeopardy (IJ) was declared for the facility's failure to ensure that post-discharge services were set up for Resident #4 prior to their discharge date . An IJ summary tool was provided to the facility. The facility submitted a plan for removal at 2:10 pm that was not accepted, the second draft submitted at 3:09 pm, the third submitted at 4:05 pm and fourth submitted at 4:44 pm were not accepted. […]

• Actual harm, isolatedF600Sep 25, 2023

  Based on record review and interview, it was determined that facility staff failed to provide an environment for residents which was free from abuse. The deficient practice resulted in a harm for Resident #74, #256, and #34. This was evident for 4 (Resident #74, #256, #7, and #34) of 16 residents investigated for abuse. The findings include: Dementia is not a specific disease, but is instead a general term for the impaired ability to remember, think, or make decisions that interfere with everyday activities. A care plan is a guide that addresses each resident's unique needs. […]

• Actual harm, isolatedF689Sep 25, 2023

  Based on record review and interview, it was determined that facility staff failed to provide the supervision needed to prevent resident to resident altercations which resulted in harm. This was evident for 1(#74) of 7 residents reviewed for accidents. The findings include: Dementia is not a specific disease, but is instead a general term for the impaired ability to remember, think, or make decisions that interfere with everyday activities. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. […]

• No harm, potential for more than minimal, patternF584Oct 9, 2025

  Based on observation and interviews it was determined that the facility failed to ensure a sanitary and homelike environment. This was found to be evident on two out of two nursing units in the facility.The findings include: 1) On 10/1/25 at 12:58 PM surveyor observed the sink in the bathroom shared between rooms [ROOM NUMBERS]. Multiple cracks were observed around the drain and in the basin of the sink. On 10/09/25 at 10:53 AM surveyor and the Director of Nursing observed the cracks in the bathroom sink located between rooms [ROOM NUMBERS]. On 10/09/25 at 12:33 PM during an interview, the Maintenance Supervisor (Staff #14) reported that he was aware that some of the sinks were in rough shape and that they had replaced some of them. […]

• No harm, potential for more than minimal, patternF803Oct 9, 2025

  Based on interview and pertinent document review it was determined that the facility failed to have a process in place to ensure that residents received the items listed on the meal ticket or specific items that were requested by the residents. This was found to be evident for 2 residents (Resident #70 and #15) during random dining observations and one (Resident #2) during an interview with the resident council.The findings include:1.On 10/02/2025 at 1:09 PM Resident # 70, a long-term resident of the facility and without cognitive decline was interviewed. Resident #70 reported that a week before s/he was not served a BBQ sandwich that was on the facility menu and her/his meal ticket. Resident #70 reported that s/he was looking forward to the BBQ sandwich all day. […]