Cummings Health Care Facility

In the surveyor’s words

From the most serious findings on record at Cummings Health Care Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 1, 2022

  Based on record review, interviews and review of the Emergency Medical Services Patient Care Report, the facility failed to supervise and monitor 1 of 2 (Resident #1) wandering resident resulting in the resident eloping from the facility; wandered a mile away from the facility, going over a bridge and being found in a traffic rotary. Because of the facility's failure, the resident eloped; during this elopement the resident had a fall and sustained a head abrasion, cuts, and bruises. Finding: On 11/15/22, a review of Resident #1's clinical record was completed. Resident #1 was admitted in September 2022 with a diagnosis of Dementia with behaviors. […]

• Actual harm, isolatedF689Mar 5, 2024

  Based on record review and interviews, the facility failed to provide necessary assistance to prevent accidents by failing to ensure that a two-person mechanical lift assist was provided during transfer for 1 of 1 resident (Resident#1 [R1]) reviewed for an incident with injury. This fall resulted in R1 falling during an improper transfer from bed to shower chair and R1 sustaining a fractured left arm and left ankle. Findings: On 3/5/24, R1's clinical record was reviewed. The record indicated R1 was diagnosed with dementia, weakness, neuropathy, limited mobility, and other morbidities. On 12/7/23 at 1:30 p.m., a nurse note indicated: C.N.A.1 had another staff member tell writer (Registered Nurse [RN]) to come to residents' room immediately. […]

• No harm, potential for more than minimal, widespreadF725Jul 1, 2026

  Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).Findings:Review of Payroll Based Journal staffing report revealed the facility triggered for excessively low weekend staffing during the second quarter of 2026 (January 1 - March 31).On 7/1/26 at approximately 12:45 p.m., during an interview with the Administrator and a surveyor, the staffing schedules were reviewed for the second quarter of 2026. The surveyor confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends.

• No harm, potential for more than minimal, widespreadF909Jul 1, 2026

  Based on observations and interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bedrails as part of a regular maintenance program to identify areas of possible entrapment for 30 of 30 beds. This has the potential to affect the safety of all residents.Findings:On 6/29/26 at 11:03 a.m., a surveyor observed that the mattress for bed 1 in room [ROOM NUMBER] did not fit the bed frame. There was a large gap between the mattress and the headboard creating a potential space for entrapment of body parts.On 6/29/26 at 2:36 p.m., 2 surveyors observed that the mattress in room [ROOM NUMBER] (bed 1) did not fit the bed frame. There was a large gap between the top of the mattress and the headboard creating a potential space for entrapment of body parts. […]

• No harm, potential for more than minimal, widespreadF801Jun 11, 2025

  Based on interviews, the facility failed to ensure the Food Service Supervisor (FSS) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents (32 residents). Finding: On 6/9/25 at 10:45 a.m., during an interview with a surveyor, the FSS stated that she has been in this role for about one year. She stated that she does not have the qualifications for the job and that she is currently not enrolled in any qualifying course or a Managerial Servsafe course. She then stated the facility's dietician is on a consultant basis and comes in monthly. […]