Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Care And Rehab - Cumberland during CMS and state inspections, most recent first.
Failure to Provide Consistent PI Care: A resident at risk for skin breakdown developed worsening wounds after a LLE fracture and casting. Nursing documented a toe wound with bacitracin and dressings, but the facility did not add new interventions, complete a comprehensive weekly assessment, or notify the provider when the wound enlarged. Surveyors later found the resident still in a post-op shoe and splint instead of the recommended CAM boot, with multiple foot wounds and an undocumented heel dressing; the DON and IC RN were unaware of the heel injury, and the wound provider identified new PI including a stage 3 heel ulcer and a stage 1 dorsal foot ulcer.
The facility failed to document adequate behavioral monitoring for two residents receiving psychotropic medications. One resident with anxiety and depression was ordered Trazadone and Fluoxetine, and another resident with Alzheimer’s disease, dementia, and depression was ordered Venlafaxine HCl; however, the DON stated the facility only monitored antidepressants if depressive behaviors appeared and had no further behavioral monitoring documentation for either resident. The record also showed a GDR recommendation for Effexor that was not addressed.
Failure to provide required discharge and transfer documentation for two residents. One resident with intact cognition had no bed hold or written notice of transfer, and the NHA stated staff only told the resident/rep why the resident was being sent out and documented it in the chart. Another resident with severe cognitive impairment had no Ombudsman notification or notice of transfer on file, and the NHA stated the facility did not have the documentation because the resident remained in the computer system after transfer and the monthly Ombudsman notification process overlapped with the transfer.
Failure to Complete PASRR Level II Screening: A resident admitted with schizoaffective disorder and receiving psychotropic meds, including Buspirone HCL, Clozapine, and Lorazepam, had a Level I PASRR indicating a major mental disorder and need for a Level II screen. Surveyor follow-up found the facility did not have a PASRR II on file, and the DON could not confirm that one had ever been completed.
Failure to Care Plan High-Risk Medications: A resident with DM, CKD, AFib, CHF, and weakness was receiving Apixaban, Furosemide, and Lantus, but the care plan and MAR did not document bleeding risk, diuretic risks, or insulin/hypoglycemic risks. The CNA reported no specific guidelines beyond reporting anything out of the ordinary, and the DON stated there were no specific side effects, risks, or monitoring interventions identified for the resident’s high-risk meds.
A resident with multiple chronic conditions had a PHQ-9 increase from minimal depression to moderate depression, along with documented statements about feeling depressed and thoughts of suicide. Although staff noted mood concerns, offered talk therapy, and briefly monitored behaviors, the care plan and treatment record did not reflect the resident’s changed mental status or include interventions for monitoring suicidal thoughts. During survey interviews, the resident reported contemplating suicide and a plan to obtain narcotics, while the DON stated the issue had been handled as a one-time situational event.
A resident with a left tibia/fibula fracture and significant assistance needs was supposed to transition from a temporary splint and post-op shoe to a tall Cam boot for transfers. Surveyors found the resident still wearing the temporary devices instead of the ordered boot, and interviews with the DON, PT, orthopedic surgeon, and NHA showed the boot order was received but not ordered right away. The orthopedic surgeon stated the Cam boot was needed as soon as possible for stability during transfers.
Failure to Use Care-Planned Dycem in Recliner: A resident with dementia, cognitive impairment, and multiple chronic conditions was transferred into a recliner without the care-planned dycem pad in place. The resident had previously fallen from the recliner after reporting the chair started lifting and did not stop. Surveyor observation found CNAs placed the resident in the recliner without the dycem, and a CNA said she was unsure whether it was there and did not place it during the transfer.
The facility failed to maintain an infection prevention and control program for two residents with PEG tubes who were not placed on EBP. Surveyors observed missing EBP signage and PPE at room entrances, staff providing hands-on care without gowns, and an LPN entering a resident’s room without hand hygiene, using gloves stored in a scrub pocket, and performing PEG tube care without sanitizing hands between glove changes. Staff interviews confirmed confusion about when EBP applied and acknowledged that hand hygiene was not performed as expected.
The facility did not have an effective antibiotic stewardship system within its IPCP to monitor antibiotic use. A resident with a UTI diagnosis was started on Cephalexin by hospice without UA or UC&S, and the resident said they expected lab work before an antibiotic was started. The DON and IC noted hospice was treating without lab work, and the IC stated the resident's symptoms alone did not meet McGeer's criteria.
A resident with multiple health conditions and moderate cognitive impairment fell during a transfer when a CNA failed to use a gait belt and non-slip footwear as required by the care plan. The facility's investigation was limited to the involved parties and did not include interviews or assessments of other residents for similar safety or neglect concerns, contrary to facility policy.
Surveyors identified that controlled medications, including narcotics and Lorazepam, were not consistently documented or stored according to professional standards. Several residents had discrepancies between narcotic sign-out sheets and MARs, with missing or incorrect entries, and some narcotic volumes were not properly tracked. In one instance, a narcotic spill was not verified by a second nurse as required. Additionally, Lorazepam was found stored without a double lock, and staff were unclear about storage requirements.
The facility failed to ensure RN assessments after falls for two residents, one with Alzheimer's and a recent hip fracture, and another with dementia and a history of falls. LPNs conducted initial assessments without RN follow-up, contrary to facility policy and state regulations.
A resident with a history of dementia and repeated falls experienced ten falls over three months, with the facility failing to implement timely interventions or identify root causes. Despite the facility's policy requiring updates to care plans after falls, new interventions were not consistently added, and root causes were often not identified. The Director of Nursing acknowledged the need for improvement in the facility's falls policy and procedures.
The facility failed to document education and offer of the influenza vaccine to residents with complex medical conditions, such as Parkinson's and diabetes mellitus, for the years 2023 and 2024. Interviews revealed a misunderstanding of the policy regarding annual declination documentation, contributing to the deficiency.
Failure to Provide Consistent Pressure Injury Care
Penalty
Summary
The facility failed to provide consistent pressure injury care for a resident admitted with multiple diagnoses including atrial fibrillation, peripheral vascular disease, hypertension, weakness, and a history of bilateral buttock pressure injuries on admission. The resident was assessed as requiring substantial maximal assistance for bed mobility, transfers, toileting, and footwear management, and was identified as at risk for pressure injuries. The care plan included skin protection measures, repositioning, pressure-relieving surfaces, skin treatments, nutritional support, and weekly wound monitoring. After the resident sustained a left tib/fib fracture and returned with a cast, the record showed development of a left lateral 5th toe wound that was later described as larger under the cast. Nursing notes documented cleansing and application of bacitracin, telfa, gauze, and border foam, but the report states the facility did not implement new interventions for the pressure injury, did not notify the provider on call when the wound deteriorated, and did not complete a comprehensive weekly assessment. The resident also reported that the facility had not been taking care of the leg, that the ace wrap was not removed often, and that the leg was not being looked at regularly. The report further states that the resident developed additional in-house pressure injuries related to the cast and splint. On orthopedic follow-up, the resident was noted to have pressure injuries to the left medial foot, left lateral foot, and left upper shin area from the cast. Later, surveyors observed the resident still wearing a post-op shoe with posterior splint instead of the recommended CAM boot, and found three wounds on the left foot plus a dressing on the left heel with no dates or initials. The DON and IC RN were unaware of the heel wound, and the wound provider later identified a new stage 1 pressure injury on the dorsal left foot and a new stage 3 pressure injury on the left heel, which were attributed to pressure from the post-op shoe strap and temporary splint. Surveyors found no interventions in place after discovery of the heel pressure injury.
Incomplete Behavioral Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had adequate behavioral monitoring documented for two residents reviewed for unnecessary medications. The facility policy titled, PSYCHOTOPIC MEDICATIONS, stated that targeted behaviors for which the drug is administered must be entered on the behavior monitoring record, the effectiveness of the psychotropic drug must be documented each shift, and the behavior monitoring record must be reviewed quarterly. However, the Director of Nursing stated that the facility only did behavior monitoring and charting by exception as needed, and that antidepressants were monitored only if residents started showing depressive behaviors. One resident was admitted with a BIMS score of 14/15, indicating cognitive intactness, and had diagnoses of anxiety and depression. The resident’s physician orders included Trazadone 50 mg at bedtime for sleep related to major depressive disorder and Fluoxetine 60 mg in the morning for depression related to major depressive disorder. The care plan addressed psychotropic medication risks and mood/behavior symptoms, but when the surveyor asked for behavioral monitoring documentation, the DON stated there was no further documentation for behavioral monitoring for this resident. A second resident was admitted with diagnoses including Alzheimer’s disease, dementia, and muscle weakness, and had a BIMS score of 10/15 indicating moderate cognitive impairment. The resident’s physician orders included Venlafaxine HCl 75 mg twice daily for unspecified depression, and a GDR note recommended assessing for a trial GDR of Effexor or documenting why it was contraindicated. The provider discontinued Aricept but did not address Effexor or trial a GDR. When asked for behavioral monitoring documentation for this resident, the DON again stated there was no further documentation for behavioral monitoring.
Failure to Provide Required Discharge and Transfer Documentation
Penalty
Summary
The facility did not provide proper discharge documentation for 2 of 2 residents reviewed for discharge. For one resident, who was admitted with a BIMS of 13/15 indicating cognitive intactness and had MDS assessments stating discharge return anticipated, the surveyor could not find a bed hold for the discharge to the hospital or a notice of transfer form. The DON asked what needed to be on the notice of transfer, and the NHA stated there was no bed hold because the resident and representative did not want the resident to return to the facility. The NHA also stated the facility did not have notice of transfer documentation and that staff told the resident or representative why the resident was being sent out and documented it in the medical chart, but did not give a written notice in language they understood. For the second resident, who had a BIMS of 00 indicating severe cognitive impairment and an MDS stating discharge return anticipated, the surveyor could not find Ombudsman notification and notice of transfer documentation for the discharge. The DON again asked what needed to be on the notice of transfer, and the NHA stated the facility did not have the notice of transfer documentation. The NHA also stated the resident was transferred out on 10/31/25, the resident was not removed from the computer system in case of a short stay, and social services sent Ombudsman notifications on the 3rd day of the month, but there was an overlap between the transfer and the social worker's notification so the Ombudsman notification never happened.
Failure to Complete PASRR Level II Screening
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed for a resident admitted with schizoaffective disorder and prescribed psychotropic medications, including Buspirone HCL, Clozapine, and Lorazepam. Based on record review, a Level I PASRR screening completed on 03/24/25 identified that the resident had a major mental disorder and had taken psychotropic medications to treat symptoms or behaviors of a major mental disorder, indicating that a Level II PASRR should have been completed. The report also notes that the earlier Level I PASARR indicated a hospital discharge 30-day exemption from a Level II screening. During surveyor follow-up, the DON was asked for a copy of the resident’s abbreviated PASRR Level II. On 02/18/26, the DON stated the facility did not have a PASARR II for the resident and reported that the Social Worker was on vacation. The DON also stated she called the Social Worker and was still unable to locate or confirm that a PASARR II had ever been completed for the resident.
Failure to Care Plan High-Risk Medications
Penalty
Summary
The facility did not develop and implement a person-centered care plan for R5 that addressed the resident’s high-risk medications and related needs. R5 was admitted with diagnoses including diabetes mellitus with chronic kidney disease, atrial fibrillation, congestive heart failure, obstructive and reflux uropathy, and weakness. The quarterly MDS completed on 12/10/25 indicated R5 had a BIMS score of 14/15 and was receiving an anticoagulant, a diuretic, and a hypoglycemic medication. R5’s medications included Apixaban 2.5 mg by mouth twice daily for atrial fibrillation, Furosemide 20 mg by mouth daily for chronic kidney disease and congestive heart failure, and Lantus insulin 50 units subcutaneously daily for type 2 diabetes mellitus with diabetic chronic kidney disease. Review of R5’s care plans and MAR did not document a plan of care for bleeding risk, diuretic risks, or insulin/hypoglycemic risks. The facility policy titled Care Planning stated to see AMDA guidelines, and the AMDA guidelines referenced care plan interventions as specific, actionable steps for nursing staff, including monitoring, non-pharmacological interventions, and pharmacological management. During interview, a CNA stated the CNAs did not have specific guidelines to look for residents and would report anything out of the ordinary. The DON stated any changes such as bleeding or side effects of high-risk medications would be reported and followed up on, but there were no specific side effects or risks identified in residents’ care plans or on the MAR, and no specific care plan interventions or monitoring identified for nursing staff to watch for with R5’s high-risk medications.
Care Plan Not Updated for Resident’s Increased Depression and Suicidal Statements
Penalty
Summary
The facility did not ensure that R5’s care plan was revised to reflect changes in mood and increased depression, and it did not direct staff in providing necessary care and services. R5 was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, prostate cancer, and weakness. R5’s 9/9/25 MDS PHQ-9 score was 01, indicating no or minimal depression, and the most recent quarterly MDS documented intact cognition with a BIMS score of 14/15. On 12/15/25, R5’s PHQ-9 score increased to 10, indicating moderate depression. Social service documentation noted that R5 reported little interest in doing things, feeling depressed, trouble sleeping, feeling tired, and thoughts that he would be better off dead but would not hurt himself. The note also documented that talk therapy was offered, and communication occurred with the MD, resident, DPOA, guardian, and dietary on the plan of care, but behavior and mood were not addressed in the care plan or treatment record. Subsequent documentation showed continued concerns about R5’s mood and suicidal statements. On 12/21/25, the medical record noted that R5 reminisced with a nurse, described past depression and thoughts of suicide, and stated the holidays were a difficult time; q shift behavioral monitoring for 7 days was initiated. On 12/22/25, R5 expressed depression about being in the nursing home and not being home, and staff encouraged him to focus on enjoyable activities and achievable goals. The treatment record for 12/21/25, 12/22/25, 12/23/25, 12/24/25, and 12/27/25 documented no comments or behaviors noted. A late entry on 2/14/26 recorded that R5 stated, "I pay you enough to do just enough so I don't kill myself," and staff documented that he denied current safety or self-harm concerns and said the statement was made out of frustration. During survey interviews on 2/17/26, R5 told the surveyor he had contemplated suicide and had verbalized a plan to get narcotics, and he reported speaking with facility staff including the social worker. The SW designee/CNA and DON were interviewed, and the DON stated the issue had been addressed through the 7-day behavioral monitoring, but the care plan still did not address R5’s change in condition or include interventions for monitoring behaviors or awareness of suicidal thoughts.
Failure to Provide Ordered Cam Boot for Transfers
Penalty
Summary
The facility did not ensure that a resident receiving PT and orthopedic care had the ordered Cam boot available for transfers, as directed by the orthopedic surgeon. The resident was admitted with multiple diagnoses including atrial fibrillation, hypertensive heart disease, peripheral vascular disease, osteoarthritis of the left ankle and foot, hypertension, weakness, and a right artificial hip joint. The resident’s MDS showed substantial to maximal assistance was needed for bed mobility, footwear, rolling, sitting, chair-to-bed, toileting, and transfers. Orthopedic notes documented a left tibia/fibula fracture and stated that the resident could transition from a temporary splint to a tall Cam walking boot, with weight bearing as tolerated for transfers in the boot and 25% weight bearing for distance in the boot. The resident told the surveyor that during a PT transfer in the bathroom, the resident felt and heard a pop with a burning sensation, later went to the ER, and returned with a cast for a displaced left fibula fracture. The resident also stated that the post-op shoe was hurting during transfers and even while sitting in the wheelchair. Survey observations and interviews showed the resident was still wearing a post-op shoe and posterior splint instead of the ordered Cam boot after the orthopedic recommendation was scanned into the record. The DON confirmed the resident still had the post-op shoe and posterior splint, and the orthopedic surgeon stated the temporary splint and post-op shoe were only to be used temporarily and that the resident absolutely needed the Cam boot as soon as possible for stability during transfers. PT staff reported the Cam boot order was received but not ordered until a week later, and the NHA confirmed the boot was ordered later and should have been ordered when the orthopedic recommendations were received.
Failure to Use Care-Planned Dycem in Recliner
Penalty
Summary
The facility did not ensure a resident was safe in the environment to prevent the risk of falling when the resident was placed in a recliner without the dycem pad that was care planned to be used while the resident was sitting in the recliner. The resident, who was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia, hypertensive kidney disease stage 1-4, Alzheimer's disease, benign neoplasm of cerebral meninges, nonrheumatic aortic stenosis, dementia, personal history of MRSA, and muscle weakness, had an MDS assessment showing a BIMS score of 10/15 and moderate cognitive impairment. The fall risk care plan identified the resident as at risk for falls related to disease process and dementia and included dycem in the recliner as an intervention. A fall note documented that the resident was found on the floor in front of the recliner after stating the chair started lifting and did not stop. Surveyor observation later showed two CNAs transferring the resident from bed to recliner with a Hoyer lift, and the resident was placed in the recliner with no dycem in place on the seat. The CNAs exited the room without placing the dycem, and one CNA stated she was unsure whether the dycem was in the recliner and did not place it during the transfer. The DON stated staff should make sure the dycem is in the recliner whenever the resident is in it and should have verified it was in place before the resident was seated.
Infection Prevention and Control Program Not Maintained for Residents With Feeding Tubes
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program for residents with indwelling medical devices and for staff performing resident care. Two residents, both with feeding tubes, were identified as not being on Enhanced Barrier Precautions (EBP) when surveyors reviewed their care and observed staff interactions. The facility policy stated that EBP is to be implemented for residents with indwelling medical devices, including feeding tubes, and that it is intended to prevent transfer of multidrug-resistant organisms during high-contact care activities. One resident was observed without EBP signage or PPE at or near the room entrance, despite having a PEG tube and requiring dependent care. Surveyors observed CNA care that included incontinence care, a partial bed bath, dressing, and transfer with a Hoyer lift; hand hygiene, gloves, and a mask were used, but no gown was worn. Staff interviewed about the resident’s EBP status stated they were unsure why the resident was not on EBP, and the DON stated the resident did not require EBP because the PEG site was healed even though the tube remained in place. For another resident with PEG tube orders for site care, tube feeding, and free water flushes, surveyors observed no EBP sign or PPE cart outside the room. An LPN entered without sanitizing hands, did not don PPE before gathering supplies, and placed supplies on a contaminated bedside table. The LPN later donned a gown and used gloves taken from a scrub pocket, then performed PEG tube care, including flushing, removing the old dressing, and applying a new dressing, without sanitizing hands between glove changes or before exiting the room. The LPN acknowledged hand hygiene should have been used and did not, and the IC RN stated staff are not to store gloves in scrub pockets and that the EBP signage and use had been unclear.
Antibiotic Stewardship Program Not Followed
Penalty
Summary
The facility did not establish an Infection Prevention and Control Program that included an antibiotic stewardship program with a system to monitor antibiotic use. Facility policy required the nurse to use standardized infection criteria, notify the physician or practitioner with evaluation information, and have the prescriber identify the diagnosis, indication, dose, duration, and route when an antibiotic was ordered. The policy also stated the Infection Preventionist would track antibiotic use and monitor adherence to evidence-based criteria. For one resident admitted with a diagnosis of UTI, hospice ordered Cephalexin 500 mg by mouth twice daily for five days. The antibiotic was started without a urinalysis or urine culture and sensitivity. When surveyed, the resident stated hospice placed them on the antibiotic to see if it helped and that they would normally expect lab work before being started on an antibiotic. The DON provided a comment to the provider noting hospice was treating without UA/UC and that McGeer's criteria were discussed. The IC stated the resident had urgency and hesitancy, but also said the antibiotic did not meet McGeer's criteria based on symptoms alone and that the resident had a history of urgency before admission.
Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation following a fall incident involving a resident with multiple diagnoses, including palliative care, atrial fibrillation, congestive heart failure, unspecified dementia, chronic kidney disease, and a history of falling. The resident, who had moderate cognitive impairment and required an assist of one with a gait belt and walker for transfers, fell during a transfer from the bathroom to a wheelchair. At the time of the fall, the resident was not using a gait belt or non-slip footwear as specified in the care plan. The Certified Nursing Assistant (CNA) involved did not follow proper safety measures during the transfer. After the incident, the facility's investigation was limited to interviewing the resident and the CNA involved. There was no documentation that other residents were interviewed or assessed for similar concerns regarding the CNA's transfer practices. The Director of Nursing confirmed that no additional residents were interviewed to determine if there were other instances of unsafe transfers or potential neglect. This lack of a comprehensive investigation did not align with the facility's abuse prevention policy, which requires a systematic approach, including interviewing other residents to assess for possible abuse or neglect.
Deficient Controlled Substance Documentation and Storage
Penalty
Summary
Surveyors found that the facility failed to ensure controlled medications were administered and documented according to professional standards for multiple residents. For several residents receiving narcotic medications, there were discrepancies between the narcotic sign-out sheets and the Medication Administration Records (MARs). In some cases, doses were signed out on the narcotic sheets without corresponding documentation in the MAR, and in other instances, the MAR indicated administration without a matching entry on the narcotic sheet. Additionally, incorrect doses were documented, and initial volumes of medication were not always properly recorded when narcotics were dispensed and stored in the medication cart. Further review revealed inconsistencies in the counting and documentation of remaining narcotic volumes, with some staff recording increases in volume that were not possible, and explanations provided by staff and the Director of Nursing (DON) indicated a lack of clarity and adherence to proper procedures. In one case, a narcotic spill was documented by a nurse without a second licensed nurse verifying and signing off on the incident, contrary to facility policy. The DON acknowledged that the expected process was not followed and that discrepancies persisted despite previous education and audits. Additionally, a controlled substance (Lorazepam) was observed stored in a medication room refrigerator without being double locked, as required. Staff, including the RN and DON, were either unaware or unsure of the double-lock requirement for this medication. These findings demonstrate a pattern of inadequate pharmaceutical services and failure to meet regulatory requirements for the handling, documentation, and storage of controlled substances.
Failure to Ensure RN Assessment After Resident Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically after falls occurred. In the case of one resident, who was admitted with Alzheimer's disease and a recent hip fracture, the facility did not conduct a proper assessment after the resident fell and fractured their left hip shortly after admission. The initial assessment was conducted by an LPN, who moved the resident to a recliner without an RN's assessment. The Director of Nursing later assessed the resident when they complained of pain, but there was no initial fall report or assessment documented by the staff member on duty at the time of the fall. Another resident with a history of dementia, stroke, and repeated falls also did not receive an RN assessment after falls occurred. Documentation showed that assessments were completed by LPNs without subsequent RN evaluations to ensure there were no injuries or changes in condition. The facility's policy and state regulations require that an RN assess residents after falls, but this was not adhered to, leading to a deficiency in the standard of care provided.
Failure to Implement Timely Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement new care planned fall interventions for a resident, identified as R29, who was at high risk for falls. Despite multiple fall incidents, the facility did not consistently identify root causes or update the care plan with new interventions. R29, who had a history of dementia with agitation, repeated falls, and other health issues, experienced ten falls over a three-month period, some resulting in minor injuries. The facility's policy required the assessment and evaluation of safety precautions and the updating of care plans, but this was not adequately followed. R29's care plan included various interventions such as sensor alarms and therapy evaluations, but these were not consistently updated following each fall. For instance, after falls on 07/20/24 and 07/29/24, no new interventions were implemented, and root causes were not identified. Similarly, after falls on 08/24/24 and 08/25/24, the care plan was not updated to address the identified toileting need, which was a root cause for these incidents. The facility also failed to implement new interventions after falls on 09/04/24, 09/09/24, 10/09/24, and 10/11/24, despite reviewing the care plan. The Director of Nursing (DON) acknowledged that the facility's falls policy and procedures could be improved, as they were not always identifying root causes or adding interventions in a timely manner. The surveyor noted that the facility did not implement a two-hour toileting schedule for R29 until 10/24/24, despite earlier falls indicating a need for such an intervention. The DON admitted that this intervention should have been implemented sooner, highlighting a deficiency in the facility's response to fall incidents.
Deficiency in Influenza Vaccine Documentation and Education
Penalty
Summary
The facility failed to document that residents and/or their responsible parties received education regarding the benefits and potential side effects of the influenza vaccine, and whether the residents received or declined the vaccine. This deficiency was identified for three out of five residents sampled. Specifically, residents with complex medical conditions, including Parkinson's and diabetes mellitus, did not have documentation in their medical records indicating they were educated about or offered the influenza vaccine for the years 2023 and 2024. Additionally, there were no declination forms or progress notes available to confirm that these residents refused the vaccine. During interviews, the Infection Preventionist reported that the residents had refused the influenza vaccine, but could only provide a signed declination form for one resident from 2022. The Director of Nursing believed that the facility did not need to obtain a declination annually, which was contrary to the surveyor's statement that documentation of education and vaccine offer or refusal must be provided each flu season. The lack of documentation and misunderstanding of the policy led to the deficiency noted by the surveyor.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 106 citations issued within 25 miles in the last 12 months — including the 1 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
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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) |
|---|---|---|---|---|
| Barron Care And Rehabilitation | 12.2 mi | ★★★★★ | 19 | 0 |
| Dove Healthcare - Rice Lake | 13.3 mi | ★★★★★ | 15 | 0 |
| Heritage Lakeside | 14.5 mi | ★★★★★ | 15 | 1 |
| Shell Lake Health Care Center | 16.3 mi | ★★★★★ | 9 | 0 |
| Dove Healthcare - Spooner | 21.3 mi | ★★★★★ | 1 | 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.