Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cumberland Trace Health & Living Community during CMS and state inspections, most recent first.
The facility failed to prevent accidents and implement appropriate interventions for residents at risk for falls, resulting in injuries such as fractures and head lacerations. Additionally, several residents were found with medications at their bedside without proper orders or self-administration assessments, despite cognitive impairment and facility policy requiring staff supervision during medication administration.
A resident with a recent hip replacement and multiple fractures was admitted for rehabilitation and required assistance for all ADLs. The facility failed to follow wound management policies, did not document or clarify wound care orders, and left the surgical incision uncovered while the resident was placed in adult briefs and not consistently toileted. When signs of infection developed, there was insufficient documentation of wound assessment, physician notification, or appropriate wound care interventions. The resident's wound became infected, leading to hospital readmission and surgical intervention.
Surveyors found that several medications, including inhalers and sprays, were not properly labeled with resident names or dates of opening on multiple medication carts and in a medication storage room. A vial of tuberculosis testing serum was also missing an open date. Facility policy requires dating and timely disposal of such medications, but this was not consistently done.
A resident with significant medical conditions, including heart failure and Alzheimer's disease, did not have an advance directive (code status) order in their record, despite documentation in their profile and care plan indicating a desire for CPR. The DON confirmed the omission, which was not consistent with facility policy requiring care plans to reflect residents' documented treatment preferences.
The facility did not ensure accurate MDS assessments for two residents: one with dementia had falls inaccurately documented in the MDS compared to clinical notes, and another with muscle weakness and UTIs was recorded as frequently incontinent in the MDS despite documentation and staff interviews indicating she was usually continent. The facility lacked a specific policy for MDS assessments and followed the RAI manual.
Two residents did not have complete or current care plans addressing their specific needs: one lacked a care plan for CPR preferences despite a physician's order and personal wishes, and another did not have an active care plan for a history of UTIs despite multiple documented episodes and a hospital diagnosis. The absence of these care plans was confirmed through record review and staff interviews.
A resident's PICC line was dressed with a split gauze under a transparent tegaderm, covering the insertion site and preventing visual assessment, contrary to facility policy requiring the site to remain visible.
A resident experienced significant psychosocial harm due to the facility's failure to address ongoing concerns about her roommate's disruptive behavior. Despite being aware of the issue, the staff did not provide effective interventions, leading to the resident's decline in mental and physical health.
A resident was left without a call device for several hours after a bed bath, despite her care plan indicating the need for it to be within reach due to physical limitations and risk of falls. Staff interviews confirmed the oversight, and the facility lacked a specific policy on call device accessibility.
A facility failed to ensure timely assessment and treatment of a resident's new open areas on the skin. Despite the resident having multiple diagnoses, including a stage 4 pressure ulcer, there was a lack of documentation and timely intervention for a new stage 2 pressure ulcer. The facility's Skin Assessment Policy was not followed, leading to a gap in care and documentation.
The facility failed to follow physician orders for oxygen administration and storage of oxygen equipment for two residents. One resident was found with a nasal cannula connected to an oxygen tank set at 0, causing shortness of breath, while another resident had undated oxygen tubing and a humidifier bottle. Staff interviews confirmed that CNAs were not authorized to adjust oxygen flow, and facility policies required dating and labeling of oxygen equipment, which were not followed.
Failure to Prevent Accidents and Ensure Medication Safety
Penalty
Summary
The facility failed to prevent accidents and implement appropriate interventions for residents at risk for falls and injury. One resident with a history of falls and a care plan requiring bilateral side rails was moved to a new room without the side rails or alternative interventions in place. This resident subsequently rolled out of bed, sustained a head laceration and a humeral head fracture, and required orthopedic evaluation. Documentation showed that the need for side rails or other interventions was not reassessed or implemented after the room change, despite the resident's known fall risk and previous similar incidents. Two additional residents with repeated falls and injuries did not have new interventions implemented or documented after their respective falls. One resident fell in the hallway while seeking assistance and sustained a right hip fracture, but the care plan was not updated with new interventions addressing the root cause. Another resident was found on the floor in his bathroom and later diagnosed with a right femoral neck fracture, yet the record lacked documentation of interdisciplinary team follow-up or new interventions to prevent future falls. The facility's fall prevention policy requires root cause analysis and new intervention strategies after each fall, but this was not followed for these residents. The facility also failed to prevent potential accidents related to medication safety. Multiple residents were found with medications at their bedside without orders or assessments for self-administration. One resident had topical medication on the nightstand, another had an inhaler and an over-the-counter medication without an order, and two residents with cognitive impairment had pills accessible in their rooms. Records lacked up-to-date self-administration assessments for these residents, and facility policy requires that staff remain with residents to ensure medications are taken as prescribed. These lapses created the potential for medication errors and harm.
Failure to Provide Appropriate Wound Care and Monitoring Resulting in Infection
Penalty
Summary
A resident with a recent total right hip replacement and additional non-operable fractures was admitted to the facility for rehabilitation. Upon admission, the resident was dependent for bed mobility and required assistance for all activities of daily living. The hospital discharge documentation indicated the surgical incision was healing well, and the resident had previously used a PureWick device and bedside commode to keep the incision clean and dry. However, at the facility, the resident was placed in adult briefs, the surgical incision was left uncovered, and staff did not consistently assist the resident to the toilet, resulting in prolonged periods in soiled briefs. The resident expressed concerns about wound infection risk and requested toileting assistance, but her preferences were not accommodated due to her transfer needs. The facility's records lacked initial and ongoing assessments and descriptions of the surgical incision site, as well as documentation of treatment orders or physician clarification for wound care. Although care plans referenced the surgical incision and the need to provide treatment per physician order, there were no specific interventions or precautions documented to protect the wound from contamination. When drainage and signs of infection developed at the incision site, there was insufficient documentation of physician notification, wound assessment, or implementation of appropriate wound care, such as covering the draining wound. Progress notes indicated ongoing drainage, foul odor, and infection, but lacked detailed wound descriptions and timely communication with the physician. Despite the resident's increasing symptoms and the development of a wound infection, the facility did not document the initiation of appropriate wound care interventions or consistent monitoring. The resident's condition worsened, leading to a hospital readmission where the wound was found to be infected with multiple bacteria, requiring surgical intervention. Facility policies required prompt assessment, documentation, and physician notification for changes in condition, as well as enhanced barrier precautions for wounds, but these were not followed, resulting in actual harm to the resident.
Failure to Properly Label and Date Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled and dated according to professional standards. On multiple medication carts and in a medication storage room, several medications, including albuterol inhalers, fluticasone sprays, and a vial of Aplisol, were found either without resident names, without dates indicating when they were opened, or both. Specifically, some inhalers were labeled only with a resident's name and lacked an open date, while others had neither a name nor a date. The Aplisol vial in the medication room was missing an open date despite being received from the pharmacy months prior. The facility's policy requires that multi-dose vials and certain medications be dated when opened and discarded within 28 days, but this was not followed in the observed instances.
Failure to Implement Advance Directive Order
Penalty
Summary
The facility failed to implement an advance directive (code status) order for a resident with multiple diagnoses, including heart failure, weakness, type 2 diabetes mellitus, and Alzheimer's disease. Upon review, the resident's record did not contain an order for an advance directive, despite documentation in the resident's profile and care plan indicating a desire to receive cardiopulmonary resuscitation (CPR). This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the order had been missed. Facility policy requires that each resident's plan of care be consistent with their documented treatment preferences and/or advance directive.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with Alzheimer's disease and dementia, documentation showed two separate incidents where the resident was found sitting on the floor, one of which involved complaints of right foot pain. Progress notes and interdisciplinary team documentation indicated no injuries were observed at the time of the falls, and subsequent notes confirmed no new wounds or injuries. However, the most recent MDS assessment inaccurately recorded the number and type of falls, indicating no falls without injury and one fall with injury, which did not align with the clinical documentation. For another resident with muscle weakness, tremors, and a history of urinary tract infections, there were inconsistencies between the resident's self-report, staff interviews, and progress notes regarding her continence status. While the resident and staff described her as usually continent with occasional incontinence, the most recent MDS assessment documented her as frequently incontinent of both bladder and bowel. The facility did not have a specific policy for MDS assessments and reported following the Resident Assessment Instrument (RAI) manual.
Failure to Implement and Maintain Resident Care Plans for Advanced Directives and UTI History
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to care plan implementation. One resident with diagnoses including sleep apnea, heart failure, hypertension, and high cholesterol had a physician's order and personal preference for cardiopulmonary resuscitation (CPR), but there was no care plan in place reflecting this advanced directive. The Director of Nursing confirmed the absence of the care plan during an interview. Another resident with a history of type 2 diabetes and pneumonia experienced multiple episodes of pain, burning with urination, and abdominal discomfort, which were documented in progress notes. Despite a positive urine dip test and subsequent hospital diagnosis of cystitis and pyelonephritis, the resident's record did not contain a current care plan addressing UTIs or a history of UTIs. A discontinued care plan was provided, but there was no documentation of an active care plan at the time of the events.
Improper PICC Line Dressing Prevents Site Assessment
Penalty
Summary
The facility failed to ensure proper dressing of a Peripherally Inserted Central Catheter (PICC) line for one resident. On observation, the resident's PICC line was covered with a clear tegaderm dressing and a 2 by 2 split gauze placed directly over the catheter and insertion site, which prevented assessment of the skin around the insertion site. The dressing was dated and initialed, but the facility's own procedure guide specifies that the insertion site should not be covered by anything other than the transparent dressing, and the site must remain visible for assessment. The improper application of the split gauze under the transparent dressing directly contradicted facility policy and prevented visual inspection of the insertion site.
Failure to Address Resident's Concerns About Roommate
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 83, was treated with respect and dignity, leading to significant psychosocial harm. Resident 83 had ongoing concerns about her roommate, Resident 30, who frequently yelled out for help, especially during the night. This behavior disrupted Resident 83's sleep, causing her to become more irritable, tearful, and isolated. Despite the staff being aware of the issue, no effective interventions were provided to address Resident 83's concerns, leading to a decline in her mental and physical health, including increased medication and weight loss. Resident 83's medical records indicated that she had a history of mild cognitive impairment, major depressive disorder, and a new diagnosis of insomnia. Before the arrival of her new roommate, Resident 83 was described as a happy and social individual. However, after Resident 30 moved in, her condition deteriorated. She began to sleep through meals, skip activities, and experience disorienting dreams. The facility's staff, including the Director of Nursing and Unit Manager, acknowledged that Resident 30's behavior was problematic and had been ongoing since at least March 2024. The facility's policies and procedures for room transfers were not adequately followed. Resident 83 was not notified about the new roommate, and there was no documentation of a meet-and-greet or psychosocial follow-up. The Social Services Director admitted that she could not remember if she had informed Resident 83 about the new roommate. The facility's failure to address Resident 83's concerns and provide appropriate interventions led to her significant decline in well-being, highlighting a deficiency in respecting and ensuring the dignity and self-determination of residents.
Failure to Ensure Call Device Within Reach
Penalty
Summary
The facility failed to ensure that a call device was within reach for a resident, leading to the resident being unable to call for assistance for several hours. On the day of the incident, the resident was observed calling out for help from her wheelchair, with the call light out of reach on her bed. The resident reported that she had been without her call light since her bed bath earlier that morning, and staff had not provided it to her when they brought her lunch. The resident's care plan indicated that she required assistance with toileting and that the call light should be kept within reach due to her physical limitations and risk of falls. Interviews with staff revealed that the call light was likely left in the bed after the bed bath, and subsequent staff who delivered lunch did not ensure it was within reach. The resident's medical history included muscle weakness, unsteadiness on feet, pressure ulcers, and other conditions that necessitated the availability of a call light for her safety and well-being. The facility did not have a specific policy related to call devices being within reach, but it was considered a standard of care. The deficiency was confirmed by the Regional Clinical Specialist and the Administrator during their interviews.
Failure to Ensure Timely Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a resident's new open areas on the skin. Resident 93, who had multiple diagnoses including a stage 4 pressure ulcer, local infection of the skin, and dementia, was observed with a note from family indicating the need for specific care measures. Despite this, there was a lack of documentation and timely intervention for a new stage 2 pressure ulcer that developed on the resident's right buttock and coccyx. The initial discovery of the new open area was noted on 11/15/23, but there was no documentation of progress notes, physician notification, or wound care between 11/15/23 and 11/20/23. It was only on 11/20/23 that the wound team classified the wound as unstageable and provided measurements and care instructions. The comprehensive care plan was initiated on the same day, indicating the need for specific interventions to manage the stage 4 pressure ulcer on the sacrum. The facility's Skin Assessment Policy, provided by the Administrator, outlined the required actions for new skin conditions, including notifying the physician, obtaining treatment orders, applying initial treatment, notifying the family, and documenting these actions in the medical record. However, these steps were not followed in the case of Resident 93, leading to a gap in care and documentation for the new pressure ulcer. The Regional Clinical Specialist confirmed that no additional documentation related to the wound was found for the period between 11/15/23 and 11/20/23, highlighting a failure to adhere to the facility's policy and ensure timely and appropriate care for the resident's pressure ulcer.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders for oxygen administration and storage of oxygen equipment for two residents. In the first case, a resident was observed with a nasal cannula connected to an oxygen tank that was not providing oxygen, as the liter flow dial was set at 0. The resident had been experiencing shortness of breath and had turned on the call light for assistance. A CNA had placed the nasal cannula on the resident but was not authorized to adjust the oxygen flow. Licensed Practical Nurses (LPNs) later adjusted the oxygen flow but did not assess the resident's oxygen level or overall condition at the time of observation. The resident's medical history included acute and chronic respiratory failure, COPD, and other conditions requiring careful oxygen management. Physician orders specified oxygen titration to maintain oxygen saturation above 90% and regular changes of oxygen equipment, which were not followed in this instance. In the second case, another resident was observed with undated oxygen tubing and a humidifier bottle on multiple occasions. The resident's oxygen was administered via nasal cannula at varying flow rates, but the equipment was not dated as required by facility policy. Interviews with staff confirmed that oxygen equipment should be dated each time it is changed, but this was not done. The resident's medical history included chronic congestive heart failure, COPD, and other conditions necessitating continuous oxygen therapy. Physician orders included specific instructions for changing and dating oxygen equipment weekly and as needed, which were not adhered to. The facility's policies on medication administration and oxygen administration were reviewed and indicated that medications, including oxygen, must be administered as prescribed and in a timely manner. The policies also required dating and labeling of oxygen equipment. The failure to follow these policies and physician orders resulted in deficiencies in the care provided to the residents, as observed and documented by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plainfield Health Care Center | 1.9 mi | ★★★★★ | 32 | 1 |
| Meadow Lakes | 4.2 mi | ★★★★★ | 5 | 0 |
| Miller's Merry Manor | 4.8 mi | ★★★★★ | 1 | 0 |
| Countryside Meadows | 4.8 mi | ★★★★★ | 15 | 0 |
| Springs Of Mooresville, The | 5.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.