Cumberland Village Care

In the surveyor’s words

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

• Actual harm, isolatedF600Sep 11, 2024

  Based on facility policy review, medical record review, facility investigation review, observations, and interviews the facility failed to protect the residents' right to be free from physical abuse by another resident for 4 residents (Resident #17 and #5, #3, and #10) of 14 sampled residents reviewed for abuse. On 4/11/2024, Resident #18 hit Resident #17 and caused a laceration above his right eye and abrasion to his left elbow. On 1/31/2024, Resident #6 hit Resident #5 in the face causing a nosebleed. On 1/11/2024, Resident #4 struck Resident #3 in the head. On 4/29/2024 Resident #11 struck Resident #10 in the arm. […]

• Actual harm, isolatedF686Feb 15, 2023

  Based on review of facility policies, medical record review, review of manufacturer instructions, and interviews, the facility failed to prevent pressure ulcers for 1 resident (#3) of 3 residents reviewed for wounds, of 15 sampled residents. The facility failures to closely monitor and document changes in Resident #3's integumentary status, the resident's compliance with the treatment plan, and the status of pre-existing wounds in accordance with facility policy, led to the failure to timely detect and intervene to address changes in the condition of a pre-existing sacral pressure ulcer and to prevent the development of new pressure ulcers. […]

• No harm, potential for more than minimal, patternF908Jan 30, 2025

  Based on facility policy review, interviews, and observation, the facility failed to ensure the kitchen equipment was maintained in good working order for 1 dishwasher and 1 hot water heater for the kitchen to ensure proper sanitization of kitchen and foodware, which had the potential to affect 156 of 158 residents. The findings include: Review of the facility's policy titled, Equipment, dated 9/2017, revealed .all foodservice equipment will be .in proper working order . During an interview on 1/30/2025 at 7:31 AM, the Maintenance Director stated the facility utilized one dishwasher in the kitchen that relied upon the hot water heater (hot water heater designated for the kitchen area) to supply the hot water and the booster temperature regulator (built-in mechanism within the dishwasher… […]

• No harm, potential for more than minimal, patternF812Jan 14, 2025

  Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen cooking and serving equipment was maintained in a sanitary condition and failed to ensure 3 dented cans and 2 containers of expired juice were discarded, which had the potential to affect 148 of 152 residents. The findings include: Review of the facility's policy titled, Equipment, dated ,d+[DATE], revealed .All foodservice equipment will be clean, sanitary, and in proper working order .All food contact equipment will be cleaned and sanitized after every use .All non-food contact equipment will be clean and free of debris . Review of the facility's policy titled, Receiving, dated ,d+[DATE], revealed .Safe food handling . […]

• No harm, potential for more than minimal, isolatedF698Jan 14, 2025

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to obtain a physician's orders for dialysis site monitoring, failed to document dialysis site assessments for thrill, bruit, and infection, and failed to complete dialysis communications records for 1 resident (Resident #71) of 1 resident reviewed for dialysis. The findings include: Review of the facility's policy titled, Dialysis: Hemodialysis (HD)- Communication and Documentation, dated 6/15/2022, revealed .Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments .Prior to patient leaving the center .licensed nurse will complete the top… […]