Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Healthcare Center during CMS and state inspections, most recent first.
Discharge planning failed for multiple residents when the IDT did not develop resident-specific plans, update goals as needs changed, or ensure needed post-discharge services and equipment were arranged before discharge. A resident with impaired cognition was discharged home without wound care, PT, OT, and HHA services in place and was later found on the floor with serious medical complications. Other residents had generalized care plans that did not reflect their wishes or documented needs such as skilled nursing, therapy, DME, and home health support.
A resident returning from the hospital after right heel wound debridement became upset over a pain med order for Percocet, believing the dose should have been 2 tabs instead of 1. During the dispute, an RN was accused of slamming discharge paperwork onto the resident's chest and then went into the hallway yelling that the resident said she hit him and that police needed to be called, which was confirmed by staff statements and the resident's interview.
A resident with an order for a rescue inhaler for SOB and wheezing was observed in distress, but the inhaler was delayed while a CMA stocked the med cart and did not report the request to the nurse. The record showed the inhaler was later documented with a late entry, and there was no nurse assessment before administration, which was not consistent with the DON’s stated practice for PRN meds.
Inadequate pain management and documentation for a resident after hospital return. A resident came back from the hospital after a heel debridement with an order for Percocet PRN, but staff delayed clarifying the order, offered Tylenol while the resident reported being told to avoid it with Percocet, and did not document the pain assessment or nonpharmacological interventions. The resident reported severe pain, said staff argued about the medication, and later received a one-time higher Percocet dose after the physician documented ongoing pain.
An LPN took a treatment cart into a resident’s room after the resident fell and was found diaphoretic, despite the facility’s practice of keeping treatment carts out of resident rooms for infection control reasons. The Infection Preventionist confirmed this was not the normal practice and said the action was unacceptable.
Surveyors found that the facility did not ensure a sanitary and homelike environment, as evidenced by cracked bathroom sinks in multiple resident rooms and persistent urine odors due to inadequate ventilation. Facility staff confirmed awareness of the damaged sinks and acknowledged that ventilation systems in some areas were insufficient for odor control and resident comfort.
A facility failed to ensure residents received menu items listed on meal tickets or requested from the always available menu. One resident did not receive a BBQ sandwich that was listed for dinner, another was told tomato soup was unavailable despite it being posted as always available, and a third resident with a fish allergy was served plain chicken instead of the breaded chicken listed on the meal ticket.
The facility failed to maintain proper hand hygiene and a sanitary environment. A resident reported staff returned a urine bottle to the bedside table without rinsing or wiping it, another resident’s urinal fell to the floor and the bedside table was not sanitized before a lunch tray was placed there, and an RN was observed changing gloves during wound care without sanitizing hands between tasks. In addition, medication storage rooms had dirty sink drains, an expired canister of disinfecting wipes, and resident specimens stored in medication refrigerators.
A resident and family member reported that a GNA on the unit was rude, mean, and aggravated in her interactions with residents. Surveyor observations showed the GNA responding to call lights in a sharp, gruff tone, and another GNA plus an RN identified the same staff member as consistently disrespectful toward residents. The DON and NHA stated they were unaware of complaints until the surveyor shared the observations.
Failure to protect residents’ personal possessions from interference by another resident. Two residents reported that a wandering resident entered their rooms, often overnight, and took items. Surveyors observed the resident wandering in other residents’ doorways while staff did not intervene. The care plan included supervision and redirection for wandering, but the record did not show these interventions were consistently implemented. An LPN stated the resident was known to wander and steal, usually food-related items, and that no permanently missing items had been identified.
Grievance information and the process for filing complaints were not readily available to residents or staff. A resident reported missing personal items, but the grievance log did not show a filed grievance. Surveyors found no grievance forms at the nursing stations or on the units, and a broken, unsecured grievance box was observed. Interviews showed the resident and a GNA did not know how to file a grievance, while an RN could not produce a form and the NHA and DON gave differing descriptions of where forms were available.
A resident’s MDS was coded incorrectly to show a functional limitation in one upper extremity even though OT notes and the DOR confirmed no upper extremity contracture or ROM issues. The DON acknowledged the MDS error, and the MDS Coordinator later stated the impairment entry was incorrect.
A resident with a history of buccal cavity cancer and a g-tube was kept NPO except for swabs dipped in water, but the facility entered a lower tube feeding order than the hospital recommended and did not add g-tube hydration orders, despite the resident’s dry mouth and the RD documenting that the resident was receiving only 33% of daily fluid needs. In a separate issue, another resident missed multiple doses of rivaroxaban, with some MAR entries lacking nursing documentation and pharmacy records showing medication had already been delivered.
Two residents had bilateral bed rails in use without documentation that alternatives were tried, safety risks were assessed, or informed consent was obtained before initiation. One resident had dementia and was dependent for bed mobility, yet the record did not show a Bed Safety Evaluation or entrapment review before rails were added to the care plan. For the other resident, the record showed a request for bed rails after a perimeter mattress was declined, but no therapy evaluation, resident education, or consent documentation was found.
Failure to review hospital records led to inaccurate diet and hydration orders for a resident with buccal cavity cancer and a g-tube. An NP approved an LPN-entered order for NPO status and reduced tube feedings without verifying the hospital H&P, which documented oral fluid tolerance, aspiration precautions, continued tube feedings, and medications via g-tube. The NP also did not identify that no hydration fluids were ordered via the g-tube, and visit notes did not address the resident’s diet orders or hydration needs.
A resident with hyperlipidemia had an order for Atorvastatin 20 mg at bedtime, but the MAR showed missed doses because the medication was waiting on pharmacy delivery. Staff could not find the medication in the cart or main supply, the nurse said it did not appear to have been re-ordered, and there was no documentation that the Omnicell interim supply was accessed when the medication was unavailable. The DON stated the facility could pull the medication from the Omnicell, but no refill delivery was documented after the original supply.
Unsecured medication carts were observed on two units, with a surveyor able to open drawers without staff noticing and find prescription topical meds and hydrogen peroxide inside. Resident specimens were also stored in med refrigerators, and expired AED electrode packages were found in a med storage room. In addition, loose insulin pens were stored in a cart drawer without proper resident-specific labeling or open dates, and staff stated this was the usual practice.
A resident’s electronic record contained conflicting MOLST forms with different CPR orders. One current MOLST ordered Attempt CPR, while another upload labeled as a voided MOLST opened to an unvoided form with No CPR orders. Staff stated the old MOLST is supposed to be voided when a new one is established, but the surveyor found both versions accessible in the record.
A resident's chart lacked documentation showing whether pneumococcal and influenza vaccines were received, refused, contraindicated, or previously given. The NHA and Infection Preventionist could not produce evidence that the resident's vaccine status had been assessed or that a vaccine was offered or refused, and the resident stated the facility did not seem to have offered it.
Failure to document a resident’s COVID-19 vaccination status. Record review showed that a resident’s chart lacked documentation of whether the vaccine was received, refused, contraindicated, or previously given. The NHA and Infection Preventionist could not produce proof that the resident’s status had been assessed, and the resident stated the facility did not appear to offer the vaccine.
Discharge Planning Failed to Ensure Resident-Specific Needs Were in Place
Penalty
Summary
The facility failed to implement an effective discharge planning process for multiple residents whose records were reviewed. For Resident #4, a discharge care plan was started after the resident chose to return to the community, but it was not developed by the interdisciplinary team, did not include the resident’s goals or treatment preferences, and did not identify the discharge location or post-discharge needs such as equipment or home health services. The plan was not regularly re-evaluated or updated as the resident’s situation changed, even though the resident later appealed insurance coverage decisions, considered long-term care Medicaid, and ultimately discharged home. Resident #4’s record also showed that a nurse practitioner documented the need for skilled nursing wound care, PT, OT, and a home health aide before discharge, but those services were not in place when the resident left the facility. Social services notes documenting discharge decisions and a referral for home health were entered late and were not added to the discharge care plan. After discharge, the resident was found on the floor in the apartment with vomit and urine, was hypotensive and hypothermic, and was diagnosed with traumatic rhabdomyolysis, acute kidney injury, and cellulitis in both lower legs. The ED record stated the resident reported wound care had not been provided since discharge. Similar discharge planning failures were identified for Residents #8, #9, and #10. Resident #8’s discharge care plan contained generalized interventions and was not updated to reflect the resident’s stated wish to go home or the specific equipment and services documented as needed, including skilled nursing, PT, speech therapy, OT, and a home health aide. Resident #9’s care plan also used generalized goals, did not reflect the resident’s discharge preferences, and did not address the need for skilled nursing, PT, OT, home health aide services, or the resident’s transfer difficulty noted during an IDT meeting. Resident #10’s discharge care plan likewise lacked resident-specific interventions and did not address the equipment and services needed after the resident’s bilateral lower-extremity amputations; the discharge summary omitted needed equipment and post-discharge services, and the resident was discharged without the hospital bed and other supports documented as needed.
Failure to Maintain Resident Dignity During Pain Medication Dispute
Penalty
Summary
Facility staff failed to ensure that a resident was treated with dignity and respect during a readmission after a hospital stay for debridement of a right heel wound. The resident had been ordered Percocet 5-325 mg every 4 hours as needed for pain. On readmission, the resident became upset when pain medication was delayed and when an LPN offered Tylenol while awaiting the Percocet from the pharmacy. The resident also believed the ordered Percocet dose should have been 2 tablets instead of 1. During the same incident, an RN was accused by the resident of slamming discharge paperwork onto the resident's chest. The RN's statement indicated that after the accusation, she left the room and yelled down the hallway that the resident said she hit him and that police needed to be called. Statements from a CNA and an LPN confirmed that the RN came out of the room yelling in the hall that the resident said she hit him and to call 911/cops. The resident later stated that staff had not treated him with dignity and respect and confirmed that the RN went out into the hallway yelling so staff and other residents could hear the accusation.
Failure to Assess Resident Before PRN Rescue Inhaler Administration
Penalty
Summary
Staff failed to provide nursing services that met professional standards of practice when a resident requested a rescue inhaler for shortness of breath and wheezing. During observation, the resident was seen sitting up in bed, pursed lip breathing, using accessory muscles, and appearing restless. The resident stated that an inhaler had been requested because breathing was difficult, but the medication had not yet been brought back, and the resident remained without the inhaler when first observed and again several minutes later. Record review showed the resident had an order for a rescue inhaler every 3 hours as needed for shortness of breath and wheezing, and the last documented dose had been given more than 4 hours earlier. A CMA stated she was aware the resident wanted the inhaler but had not returned to check on the resident and had not reported the request to the nurse. She also stated that she could administer some PRN medications without a nurse assessing the resident first, and that she was waiting because it had not yet been 3 hours. The record also showed a late entry documenting administration at a time that did not match the observation, and progress notes did not show that a nurse assessed the resident before the inhaler was given.
Inadequate Pain Management and Documentation for a Resident After Hospital Return
Penalty
Summary
Facility staff failed to provide appropriate pain management for a resident who had recently returned from the hospital after a heel wound debridement procedure. The hospital discharge summary documented Percocet 5-325 mg, 1 tablet every 4 hours as needed, and the resident was re-admitted to the facility on 1/7/26 at 8:30 PM. According to the record, the resident began complaining of pain at about 10:00 PM, and the assigned LPN realized the admission orders had not yet been signed off by the physician. The LPN documented that she offered Tylenol while waiting for the Percocet order to be signed, but the resident refused all pain medications offered. She did not document when the resident first requested pain medication, an assessment of the pain, or any nonpharmacological interventions offered. She also did not document that the resident stated he/she had been told to avoid additional Tylenol while taking Percocet, or that she educated the resident about that issue. The telehealth provider later documented that the resident reported pain at 10/10 and appeared lethargic, and did not want to increase the Percocet dose at that time, though it should be considered due to uncontrolled pain. The physician later documented that the resident had been having pain since admission and entered a one-time order for Percocet 5/325 mg, 2 tablets for pain management. The LPN documented that the resident received the 2 tablets and had no further complaints of pain. During interviews, the resident stated that staff only offered Tylenol, that he/she had told the nurse about being instructed not to take Tylenol with Percocet, and that when Percocet was finally given it was 1 tablet instead of the 2 tablets received in the hospital. The LPN, RN supervisor, DON, and administrator were interviewed, and the LPN and supervisor acknowledged they had not clarified the Percocet order with the hospital, had not offered nonpharmacological interventions, and had not documented the timing and details of the pain management events.
Treatment Cart Taken Into Resident Room
Penalty
Summary
Facility staff failed to implement an effective infection control policy and procedures when an LPN took a treatment cart into a resident’s room during a response to a fall. On 5/19/26 at 9:59 AM, a resident fell in their room on the second-floor nursing unit, and the LPN brought the treatment cart, with supplies laying on top, into the room between the bed and the wall and shut the door. The LPN later stated that treatment carts are not normally taken into resident rooms for infection control reasons, but she brought it in because she was concerned about the resident’s blood sugar since the resident was diaphoretic when found on the floor and she became anxious and inadvertently took the cart into the room. The Infection Preventionist later confirmed that it was not the facility’s practice to take treatment carts into resident rooms and stated the action was unacceptable.
Failure to Maintain Sanitary and Homelike Environment Due to Damaged Fixtures and Inadequate Ventilation
Penalty
Summary
Surveyors identified that the facility failed to maintain a sanitary and homelike environment on both nursing units. Multiple cracks were observed in the basins and around the drains of shared bathroom sinks in several resident rooms. The Maintenance Supervisor acknowledged awareness of the deteriorating condition of some sinks and confirmed that while some had been replaced, others remained in poor condition pending approval for renovation. The presence of these cracks was confirmed during joint observations with facility staff, and the issue was discussed with the Nursing Home Administrator. Additionally, a resident reported a strong urine odor in their bathroom, which was corroborated by surveyor observation. Further environmental assessment revealed inadequate ventilation in several resident bathrooms, as evidenced by the inability of air intake registers to hold a tissue in place, indicating insufficient airflow. The Maintenance Supervisor confirmed that ventilation systems in some areas only operated intermittently or when certain conditions were met, and there was no evidence provided to demonstrate that air movement was adequate for comfort or odor control. These findings were reviewed with facility leadership.
Meal Ticket and Always Available Menu Items Not Provided
Penalty
Summary
The facility failed to have a process in place to ensure residents received the items listed on the meal ticket or specific items requested by residents. During an interview, a long-term resident without cognitive decline reported that a BBQ sandwich listed on the facility menu and on the resident’s meal ticket was not served for dinner because staff said they had run out of BBQ sandwiches. Review of the meal ticket confirmed that a BBQ sandwich was listed as the primary meal for that resident. During dining observations and interviews, another resident was observed with an uneaten breakfast tray and stated that the breakfast was not liked and that oatmeal would be requested instead. The resident later requested oatmeal and also requested alternative lunch items from the always available menu, including grilled cheese and tomato soup. At lunch, the resident received grilled cheese and chicken soup and reported being told tomato soup was unavailable, even though tomato soup was posted on the always available menu and the Certified Dietary Manager confirmed it was supposed to be available and came in cans. In a resident council meeting, a third resident reported being served plain chicken instead of the breaded chicken that was supposed to be provided for lunch due to a fish allergy; staff acknowledged a kitchen error, and the Certified Dietary Manager later stated the facility had run out of breaded chicken because of unusually high requests, although the meal ticket showed breaded chicken as the resident’s primary meal and not an alternative.
Infection Control Lapses in Resident Care and Medication Storage Areas
Penalty
Summary
The facility failed to ensure proper hand hygiene and maintain a sanitary environment in a manner that minimizes the potential development and transmission of communicable diseases and infections. Resident #115, admitted for rehabilitation, reported that staff emptied a urine bottle in the bathroom but did not rinse or wipe it before placing it back on the bedside table. In Resident #17's room, the resident was admitted for rehabilitation and antibiotic therapy due to an infection. A plastic urinal was observed on the bedside table, fell onto the floor, and was picked up by the Human Resource Director and placed on the dresser. Nurse #15, who was also the Infection Preventionist, was providing care nearby, and the resident's lunch tray was then placed on the bedside table without the table being sanitized after the urinal was removed and before food service. During wound care for Resident #2, Nurse #2 was observed cleaning a dirty wound, removing dirty gloves, and putting on clean gloves without sanitizing hands between tasks. In the medication storage rooms on the second floor and the first floor, the sinks had dark green-to-black substance around the drains, tabletop dehumidifying devices were draining, and an expired full canister of Sani-Cloth wipes dated 09/2023 was present in one room. Resident specimens were also stored in the resident medication refrigerators in both rooms, with clear sleeves containing red, body-fluid-like samples. Nursing staff confirmed that storing resident specimens in the medication refrigerators was standard practice.
Disrespectful Staff Interactions With Residents
Penalty
Summary
The facility failed to ensure that residents were afforded a dignified existence and respectful communication. During the survey, Resident #7 and another resident reported concerns about a GNA on the first floor, describing the GNA’s approach, tone, and demeanor as rude, mean, and as if she appeared aggravated with the job. Resident #7, along with a family member present during the interview, specifically identified the GNA as someone who was disrespectful toward residents. Surveyor observations supported these concerns when the GNA, identified as GNA #35, responded to resident call lights with sharp, gruff statements such as, "What do you want?" and "What do you need now?" in the presence of residents. Another GNA on the unit stated that she had observed GNA #35 speak to residents in a disrespectful tone and manner consistently. A nurse on the unit also identified GNA #35 as a staff member whose resident interactions were not dignified. The DON and NHA stated they were unaware of complaints regarding the GNA’s interactions with residents and confirmed the concern regarding resident dignity when the surveyor shared the observations and staff interview findings.
Failure to Protect Residents’ Personal Possessions from Another Resident
Penalty
Summary
The facility failed to ensure residents’ personal possessions were treated with respect and safeguarded from interference by another resident. During the initial tour, two residents reported that one resident had entered their rooms at different times, most often overnight, and had taken their belongings. During later observation, that resident was seen wandering in the doorways of other residents’ rooms and was redirected twice within ten minutes by irritated residents, while three staff members present did not intervene or redirect the resident. The resident’s care plan, initiated for wandering behavior and potential elopement, included interventions to assess for hunger and toileting and to provide supervision and redirection when entering others’ rooms, but the record did not show that these interventions were consistently implemented. A nurse stated the resident was well known to wander and steal, usually food-related items, and described the behavior as not a big deal; the nurse also stated the resident was easily redirectable and that no permanently missing items had been identified. The deficiency was reviewed with the DON and NHA and confirmed.
Grievance Process Not Readily Available
Penalty
Summary
The facility failed to make grievance information and the process for filing a grievance readily available to staff and residents. Resident #77 reported that six underpants were missing and stated, "I've told everyone who comes in here." A review of the 2025 Grievance Log did not show documentation that a grievance had been filed on behalf of Resident #77 regarding the missing underpants. Surveyors observed that both nursing stations and units on levels 1 and 2 did not have grievance forms available. A broken and unsecured grievance box was observed near the level 2 elevator. During interviews, Resident #77 and a GNA stated they did not know how to file a grievance, and the GNA said many people did not know how the process worked. An RN and an LPN each described reporting complaints to unit leadership or the DON, but the RN could not locate or produce a grievance form when asked. The NHA stated grievance forms were available at the nursing station or from the computer, but not openly available, while the Director of Social Service stated grievance forms were readily available at the nursing station.
Inaccurate MDS Coding of Upper Extremity Status
Penalty
Summary
Facility staff failed to code Resident #22’s status accurately on the annual MDS assessment. During survey review, Resident #22 was observed lying in bed and reported doing well. A review of occupational therapy notes for the certification period 7/9/24–8/7/24 did not show that the resident had an upper extremity contracture, and the Director of Therapy confirmed that the resident did not have an upper extremity contracture. Despite this, the annual MDS Section GG assessment with a reference date of 8/15/25 coded the resident as having a functional limitation in one upper extremity. The DON stated that the Director of MDS had made an error and that Resident #22 did not have range-of-motion issues in either upper extremity. The MDS Coordinator later stated that documenting an upper extremity impairment was an error and that the correction was completed following surveyor intervention.
Failure to Provide Ordered Nutrition, Hydration, and Medication
Penalty
Summary
The facility failed to provide appropriate nutrition and hydration for a resident with a history of buccal cavity cancer and extensive facial surgery who had a g-tube and was ordered NPO except for swabs dipped in water. The resident’s hospital records indicated tolerance of oral fluids with aspiration precautions and continuation of tube feedings of Glucerna 1.5 at 480 mL three times daily, but the facility entered an order for only 1 can (237 mL) three times daily. No orders were entered for g-tube flushing or hydration via the g-tube, and the resident remained without those fluids while requesting water because of dry mouth. The dietitian later assessed the resident and documented estimated needs of 1680 to 1960 calories and 1600 mL of fluids daily, noting that the resident was receiving only 33% of daily fluid needs with the current tube feeding order. The dietitian recommended increasing Glucerna 1.5 to 1 can five times daily with water flushes and additional water throughout the day, but the new orders were not entered until the following day. As a result, the resident went 5 days without proper nutrition and hydration based on the report’s findings. The facility also failed to administer an anticoagulant as ordered for another resident. The resident had an order for rivaroxaban 20 mg every morning for prevention of DVT, but the MAR showed missed doses on multiple days. Nursing notes documented reasons such as waiting for pharmacy delivery or medication being unavailable for some doses, while other missed doses had no supporting nursing documentation. Pharmacy delivery records showed tablets had been delivered earlier, and the DON acknowledged the concern when the discrepancy was reviewed.
Failure to Evaluate and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that bed rails were appropriately evaluated and consented to before use for two residents. Resident #41, who had dementia and was dependent on staff for bed mobility, was observed with quarter bed rails in the up position on multiple occasions. The medical record showed bilateral bed rails were added to the care plan in April 2025 and later ordered in August 2025 to promote independence and assist with turning and repositioning, but the record did not show that alternatives were attempted or that a risk of entrapment was assessed before the bed rails were initiated. For Resident #41, the Therapy Director stated nursing would research alternatives and refer to therapy for screening, and also stated the resident would need to be re-evaluated to determine whether bed rails were still appropriate. The discharge summary from physical therapy documented poor carryover due to impaired cognition and limited new learning capacity, but it did not mention bed rails. The ADON reported that nurses were required to complete a bed evaluation quarterly and that therapy was involved if bed rails were required, but survey review found no documentation of a Bed Safety Evaluation in 2024 or 2025, and the most recent evaluation located was from 2023 when the resident did not have bed rails. Resident #88 was also observed in bed with bed rails in the up position and had a current order to maintain bilateral bed rails to promote independence with turning and repositioning. A care plan note stated the interdisciplinary team recommended a perimeter mattress, but the resident did not want it and requested bilateral bed rails instead. The record did not show that therapy completed an evaluation before the bed rails were started, and no documentation was found that the resident was educated on the risks of side rails or that informed consent was obtained. The DON described a process involving clinical discussion, therapy evaluation, physician order, and consent, but survey review of the record did not identify documentation showing those steps were completed before the bed rails were initiated.
Failure to Review Hospital Records and Enter Accurate Tube Feeding Orders
Penalty
Summary
The physician review requirement was not met for a newly admitted resident with buccal cavity cancer who had hospital records uploaded into the electronic medical record. The hospital history and physical dated 8/3/25 documented that the resident had surgical intervention, tolerated oral fluids with aspiration precautions, and was to continue tube feedings and medications via a g-tube, with Glucerna 1.5 ordered at 480 mL at 9 a.m., 2 p.m., and 7 p.m. However, facility orders entered on 8/7/25 directed the resident to be NPO except for swabs dipped in water and to receive Glucerna 1.5, 1 can three times daily, which was entered by an LPN and approved by NP #33 on 8/8/25. The NP failed to review the order for accuracy before signing it and did not recognize that no water had been ordered via the g-tube for hydration. NP #33's visit notes on 8/8/25 did not mention the resident's diet orders or the absence of hydration fluids via g-tube. On 8/11/25, the NP documented speaking with the resident's family member about concern over the amount of tube feeding and noted the resident wanted water to drink because of dry mouth, but stated the resident had to remain NPO based on the hospital orders; this was inaccurate because the hospital H&P stated the resident was tolerating fluids orally. The NP also noted consultation with the dietitian, but failed to review the hospital records and current plan of care after the concerns were raised. The RD's nutritional assessment later confirmed the resident should have received 1680 to 1960 calories daily and 1600 mL of fluids each day for hydration.
Medication Not Reordered or Obtained From Interim Supply
Penalty
Summary
Pharmaceutical services failed to meet the needs of one resident with hyperlipidemia who had an order for Atorvastatin 20 mg at bedtime. The resident’s record showed the medication had been ordered since 8/12/25, and a pharmacy delivery manifest documented that 30 tablets were delivered to the facility on that date. The MAR documented administration through 9/15/25, but the medication was not given on 9/16/25 because it was on order. It was then documented as administered for 12 days, but on 9/29/25 staff documented that Atorvastatin was not administered because they were waiting for pharmacy delivery, and it was again not given on 10/5/25 for the same reason. On 10/6/25, the MAR also showed the medication was not administered because it was awaiting delivery from pharmacy. During the survey, staff could not locate Atorvastatin in the medication cart, main supply, or overflow, and the nurse assigned to the resident stated she did not see the medication and that it did not appear to have been re-ordered. The Omnicell inventory sheet showed Atorvastatin 10 mg tablets were available in the facility, but there was no documentation that staff accessed the interim supply when the medication was unavailable. The DON stated the facility could pull the medication from the Omnicell and later reported that the resident had been opted in to sustain refill on 10/3/25, but no documentation was provided to show a refill was delivered after the initial 8/12/25 supply and before 10/7/25.
Unsecured medication carts and improperly stored insulin pens
Penalty
Summary
Medication and treatment carts were left unlocked when unattended on two nursing units. During observation, a surveyor was able to open a drawer on a first-floor treatment cart near the nursing station without staff noticing, and the cart contained prescription topical medications and hydrogen peroxide. A second treatment cart on the second floor was also observed unlocked near the nursing station, and a surveyor was again able to open a drawer without staff noticing. Both nurses acknowledged the carts should have been locked, and the facility policy stated that medication rooms, carts, and supplies must be locked when not attended by authorized personnel. The facility also stored resident specimens in resident medication refrigerators in medication storage rooms. On the second floor, a nurse unlocked the medication room refrigerator and clear sleeves containing red, body-fluid-like samples were observed inside. On the first floor, the resident medication storage room refrigerator also contained similar resident specimens. Staff confirmed that resident specimens were kept in the medication refrigerators as standard practice. In the second-floor medication storage room, expired electrode packages for an adult-size AED were also observed in the cabinets. Loose insulin pens were found in a medication cart drawer on the rear second-floor nursing unit. One resident had three open insulin pens in a resident-specific zip sleeve with no date showing when they were first opened. Two other residents had insulin pens stored in clear zip sleeves with handwritten last names on the sleeves or pens, but no resident-specific label on the pens and no open dates. A nurse stated this was the usual storage practice and that the pharmacy had them stored this way. The facility policy required medication labels to be permanently affixed to the outside of the prescription container and included the resident's name and date dispensed, and it stated that improperly labeled medications should be rejected and returned to the pharmacy.
Conflicting MOLST Orders in Medical Record
Penalty
Summary
The facility failed to maintain only one active version of a resident’s orders for life-sustaining treatment in the medical record. For Resident #3, review of the electronic medical record showed a current Maryland MOLST form in the miscellaneous section with orders to Attempt CPR. A MOLST dated [DATE] was identified as a current active order because it had not been voided, and MOLST forms are valid statewide for EMS and other medical personnel regarding CPR orders. Further review of the same electronic record’s miscellaneous section found an upload titled VOID MOLST, but when the surveyor opened it, the document contained an unvoided MOLST with conflicting orders for No CPR. During interview, the Director of Clinical Operations stated that when a new MOLST is established the old MOLST is voided and given to the social worker. The Nursing Home Administrator later stated the old MOLST was voided and showed a voided version of the [DATE] MOLST with the [DATE] MOLST upload, but the surveyor noted that staff could still access the old unvoided MOLST with conflicting orders.
Missing Documentation for Flu and Pneumonia Vaccination Status
Penalty
Summary
The facility failed to document whether Resident #117 received the pneumococcal and influenza vaccines or whether the vaccines were not given because of medical contraindications, previous vaccination, or refusal. A record review of the electronic health record showed that the resident was admitted on [DATE], but the chart lacked documentation of immunization status, vaccine history, contraindications, or refusal. During interview, the Nursing Home Administrator and the Infection Preventionist stated that the process for immunizing or verifying a new resident's vaccine status was usually completed within 5 days, but they were unable to produce documentation showing that Resident #117's vaccine status had been assessed or that a vaccine had been offered or refused. The resident stated that the facility did not seem to have offered the vaccine.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to document whether Resident #117 received the COVID-19 vaccine, had a medical contraindication, had a prior vaccination history, or refused the vaccine. Record review of the electronic health record showed that the resident was admitted on [DATE], but the chart lacked documentation of COVID immunization status or any indication that the vaccine was offered or declined. During interview, the NHA and Infection Preventionist stated that the process for immunizing or verifying a new resident's vaccine status was usually completed within 5 days, but they could not produce documentation showing that Resident #117's status had been assessed. The Infection Preventionist stated the resident must have slipped through the cracks, and the resident later stated that the facility did not seem to offer the vaccine.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 267 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allegany Health Nursing And Rehab | 1.8 mi | ★★★★★ | 19 | 0 |
| Devlin Manor Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 29 | 0 |
| Lions Rehab Center | 2.9 mi | ★★★★★ | 34 | 0 |
| Frostburg Rehab Center | 8.7 mi | ★★★★★ | 54 | 0 |
| Complete Care At Dawnview Llc | 9.5 mi | ★★★★★ | 11 | 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.