Cumberland Valley Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Oct 19, 2024

  Based on observation, interview, and record review, the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 27 sampled residents, Residents (R) 14, R33, and R58. On 08/10/2023, facility staff observed R33 in R14's room with his hands under R14's shirt. However, the facility failed to develop R33's Comprehensive Care Plan (CCP) to include interventions to address supervision and monitoring of the resident. On 09/01/2023, facility staff observed R33 in R58's room with his hand on R58's breast. […]

• Immediate jeopardy, isolatedF689Oct 19, 2024

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision to prevent sexual abuse for 3 of 27 sampled residents (Residents (R)14, R33, and R58). On 08/10/2023, staff found R33 in R14's room with his hands under R14's shirt. The facility failed to assess R33's risk for inappropriate sexual behaviors to prevent further incidents placing other residents at risk for sexual abuse. The facility created a Mood/Behaviors Care Plan on 08/11/2023 for R33; however, they failed to develop and implement interventions for the resident in order to protect other residents from potential risk of sexual abuse by him. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure proper food handling practices were followed, which had the potential to affect all residents who received meals from the dietary department. Specifically, two kitchen staff with facial hair (Cook 1 and [NAME] 2) were observed without beard restraints in place while handling food items in the kitchen. Findings included: An undated facility policy titled, Employee Sanitary Practices revealed a section titled, Procedure that specified, All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. […]

• No harm, potential for more than minimal, isolatedF557Sep 12, 2025

  Based on interview, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect for 1 (Resident 74) of 2 sampled residents reviewed for dignity and respect.Findings included: A facility policy titled, Resident Rights, reviewed 08/20/2025, indicated, Policy Statement - All residents have the right to be treated with respect, dignity and in a manner and in an environment that promotes maintenance and enhancement of quality of life. An admission Record indicated the facility admitted Resident(R)74 on 04/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder and anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF677Sep 12, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff assisted dependent residents with activities of daily living (ADLs) for 2 (Resident 2 and Resident 74) of 4 sampled residents reviewed for ADLs. Specifically, the facility failed to provide nail care for Resident 2 and Resident 74. Findings included: A facility policy titled, Activities of Daily Living (ADLs), reviewed 08/20/2025, indicated, 5. For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares. […]