Cumberland Trace Health & Living Community

In the surveyor’s words

From the most serious findings on record at Cumberland Trace Health & Living Community, in the surveyor’s own words.

• Actual harm, isolatedF684May 23, 2025

  Based on observation, interview, and record review, the facility failed to follow their policy for wound management to ensure a resident, (Resident C) received effective and appropriate treatments to prevent a non-pressure wound from becoming infected which resulted in actual harm when Resident C's wound became infected and required a hospital re-admission with a hip replacement exchange of the femoral head and liner [the plastic or metal part that sits inside the socket] for 1 of 1 residents reviewed for non-pressure wounds. Findings include: During a confidential interview, it was indicated Resident C had a total right hip replacement, but while she was home recovering, she fell and sustained a second right hip fracture and several fractures in her left foot and ankle. […]

• Actual harm, isolatedF689May 23, 2025

  A. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents for a resident (Resident 60) who had a history of falls with injury, by ensuring appropriate interventions were in place after she moved to a new room which resulted in actual harm, after she rolled out of bed and sustained an arm fracture for 1 of 9 residents reviewed for accidents; and failed to implement new interventions to prevent the potential for accidents for 2 of 9 residents reviewed for accidents (Residents 30 and 64). B. […]

• Actual harm, isolatedF550Apr 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 83) was treated with respect and dignity for 1 of 6 residents who attended and complained during an Indiana Health Department (IDOH) Resident Council meeting. This deficient practice resulted in psychosocial harm when the facility failed to provide interventions for her ongoing roommate concerns causing Resident 83 to be afraid to continue complaining about the situation, she began to lose sleep, had bad dreams, isolated herself in her room, became more tearful, and required an increase in her medication. (Residents 83 and 30). Findings include: On 4/15/24 at 11:28 a.m., Resident 83 was observed. She appeared to be asleep in her recliner. […]

• Actual harm, isolatedF689Aug 26, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident was mechanically transferred using proper technique for 1 of 3 residents reviewed for falls with injury resulting in actual harm when a resident fell during a Hoyer lift transfer and obtained multiple right leg fractures and a displaced fracture of the spine in lumbar 4 (L4) (Resident B). Findings include: On 8/25/22 at 2:08 p.m., Resident B was observed, at a different skilled nursing home facility, lying in bed with her personal blanket covering her, bunched around her waist. The resident was restless with continuous movements to include moving her hand back and forth over her abdomen and rolling her head side to side. […]

• Actual harm, isolatedF689Feb 16, 2022

  Based on interview and record review, the facility failed to ensure a resident who was totally dependent on staff for transfers, had appropriate supervision to prevent an accident which resulted in actual harm when she fell out of her wheelchair and sustained a leg fracture and [CONDITION(S)] for 1 of 4 residents reviewed for accidents (Resident B). Further, the facility failed to ensure fall risk assessments were completed in a timely manner according to facility policy for 4 of 4 residents reviewed for falls (Resident B, C, D and E). Findings include: 1. On 2/15/22 at 10:18 a.m., Resident B's record was reviewed. […]