Cumberland Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF655Jul 30, 2021

  Based on interview and record review it was determined the facility failed to provide one (1) of twenty-two (22) sampled residents (Resident #283) and their representative with a summary of the baseline care plan that included resident goals, a summary of the resident's medications, dietary instructions, and services/treatments to be administered by the facility. Prior to Resident #238's admission, the facility's Admission Coordinator obtained a list of medications from the Home Health Agency (HHA) who had provided services for the resident. However, the medication list was not accurate and did not reflect the resident's correct home medication regimen. […]

• Immediate jeopardy, isolatedF657Jul 30, 2021

  Based on interview, record review, and review of facility policy, it was determined the facility failed to revise the care plan for one (1) of twenty-two (22) sampled residents (Resident #75). The facility failed to review/revise Resident #75's care plan when the resident's exit-seeking behavior increased. On 07/02/2021, Resident #75 exited the facility via the D wing door. Staff responded to the alarm, assisted the resident inside, and implemented an intervention to monitor the resident every 15 minutes. On 07/05/2021, the facility discontinued the 15-minute checks, despite the resident's continued exit seeking behaviors, and failed to revise the care plan with interventions to monitor/supervise the resident. […]

• Immediate jeopardy, isolatedF684Jul 30, 2021

  Based on interview and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #283) received treatment and care in accordance with professional standards of practice and physician orders. The facility admitted Resident #283 to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to obtain the resident's heart rate/blood pressure as ordered by the physician on 06/18/2021, and per the facility's COVID-19 protocol. On 06/18/2021, nursing staff assessed Resident #283 to be ashy in color and cool/clammy to touch, although staff contacted the physician and sent the resident to the hospital, staff failed to obtain the resident's glucose level. […]

• Immediate jeopardy, isolatedF689Jul 30, 2021

  Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to supervise one (1) of twenty-two (22) sampled residents (Resident #75) to prevent accidents. The facility identified Resident #75 was at risk for elopement due to dementia and placed a Wanderguard bracelet on the resident on admission on 06/23/2021. Interviews with staff revealed on the evening of 07/06/2021, Resident #75 was wandering continuously and attempted to exit the building. On 07/06/2021, at approximately 9:45 PM, Resident #75 left the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF760Jul 30, 2021

  Based on observation, interview and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #283) was free from significant medication errors. The facility admitted Resident #283 to the facility on [DATE], and instead of utilizing the medication regimen the resident's POA/Caregiver provided the facility, the facility obtained an erroneous medication regimen from the Home Health agency who was providing services to the resident and administered that regimen to the resident. Subsequently, the facility administered the resident more [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] (cholesterol medication) than the resident received at home. […]