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Deficiency Records for Cumberland Healthcare Center
A list of the most recent deficiencies for Cumberland Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Cumberland Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Meet other general requirements. | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-12-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-25 | 2023-11-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-25 | 2023-11-09 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-09-25 | 2023-11-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-25 | 2023-11-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-25 | 2023-11-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-25 | 2023-11-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-25 | 2023-11-09 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-25 | 2023-11-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-09-25 | 2023-11-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-25 | 2023-11-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-25 | 2023-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-25 | 2023-11-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-25 | 2023-11-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-25 | 2023-11-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-25 | 2023-11-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-25 | 2023-11-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-25 | 2023-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-25 | 2023-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-25 | 2023-11-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-25 | 2023-11-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2023-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-11-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-25 | 2023-11-09 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-25 | 2023-11-09 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-09-25 | 2023-11-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-02-08 | 2019-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-08 | 2019-03-25 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-02-08 | 2019-03-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-08 | 2019-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-08 | 2019-03-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-08 | 2019-03-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-08 | 2019-03-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-08 | 2019-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-08 | 2019-03-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-02-08 | 2019-03-25 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-02-08 | 2019-03-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-08 | 2019-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-08 | 2019-03-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-08 | 2019-03-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-02-19 | 2019-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-19 | 2019-03-15 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-09-29 | 2017-11-12 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-09-29 | 2017-11-12 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-09-29 | 2017-11-12 | N |
| Provide housekeeping and maintenance services. | Health | 2017-09-29 | 2017-11-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-09-29 | 2017-11-12 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-29 | 2017-11-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-29 | 2017-11-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-29 | 2017-11-12 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-29 | 2017-11-12 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-09-29 | 2017-11-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-29 | 2017-11-12 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-09-29 | 2017-11-12 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-09-29 | 2017-11-12 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-29 | 2017-11-12 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-29 | 2017-11-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-09-29 | 2017-11-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-10-12 | 2017-10-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-10-12 | 2017-10-31 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2017-10-12 | 2017-10-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-10-12 | 2017-10-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-10-12 | 2017-10-31 | N |
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