Inspection Report Summary
The most recent inspection on April 24, 2025, identified deficiencies related to resident nail care, environmental cleanliness, and unsecured handrails in corridors. Earlier inspections showed a mix of compliance and similar issues with sanitation and safety, indicating ongoing challenges in these areas. Inspectors cited failures in housekeeping leading to mold presence and maintenance problems affecting corridor safety. Complaint investigations were mostly unsubstantiated, with one complaint resulting in a non-compliance finding. The pattern suggests persistent concerns with environmental conditions and safety features, with no clear improvement noted in the latest report.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 3
Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, housekeeping, and facility safety, including activities of daily living assistance, housekeeping services, and maintenance of handrails.
Findings
The facility was found deficient in providing adequate nail care to a cognitively impaired resident, maintaining clean and sanitary resident rooms and shower areas with mold-like substances present, and ensuring that handrails in hallways were firmly secured, posing potential risks to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide necessary nail care to a resident unable to perform activities of daily living, resulting in long, dirty nails with grime underneath. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide housekeeping services to ensure a clean and sanitary environment, with black, fuzzy-appearing substance (potential mold) growing around sinks, bathrooms, tiles, and shower rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure that two of four corridors were equipped with firmly secured handrails on each side, with multiple handrails loose, missing screws, or having blunt exposed ends. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents: 21
Residents affected by nail care deficiency: 1
Residents affected by housekeeping deficiency: 4
Residents affected by handrail deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SRNA 1 | State Registered Nurse Aid | Interviewed regarding nail care practices and stated she provided nail care to R6 on 04/22/2025 |
| RN 1 | Registered Nurse | Interviewed about responsibility for nail care and importance of cutting residents' nails |
| Director of Nursing | Director of Nursing (DON) | Interviewed about expectations for nursing and aide care of residents' ADLs and unawareness of housekeeping issues |
| Administrator | Facility Administrator | Interviewed about expectations for nail care, housekeeping, and maintenance reporting |
| Maintenance Assistant | Assistant Director of Maintenance | Confirmed loose handrails and responsibility for checking them |
| Restorative Nurse 1 | Restorative Nurse | Aware of loose handrails and acknowledged failure to report them |
| Housekeeping Manager | Housekeeping Manager | Interviewed about cleaning schedules and unawareness of black substance |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning handrails and responsibility for inspection |
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 3
Apr 24, 2025
Visit Reason
A Recertification and Abbreviated Survey was initiated on 04/22/2025 and concluded on 04/24/2025 to assess compliance with healthcare regulations and investigate complaints.
Findings
The facility was found to have deficit practice with a scope and severity of a 'F' level status. Deficiencies included failure to provide adequate nail care for a resident, unsafe environmental conditions such as black substance and mold in shower rooms and resident rooms, and unsecured handrails in corridors.
Complaint Details
No regulatory violations were identified for several complaints listed by their KY numbers. One complaint (KY#00039044) was found non-compliant.
Severity Breakdown
F: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure one resident received necessary nail care, resulting in long, dirty nails with black substance underneath. | F |
| Facility failed to provide housekeeping services to ensure a clean and sanitary environment; black, fuzzy substance (mold) observed in multiple shower rooms and resident bathrooms. | F |
| Corridors lacked firmly secured handrails on both sides, with loose or missing screws and parts, creating safety hazards. | E |
Report Facts
Survey Census: 87
Sample Size: 46
Sample Size for ADL Deficiency: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aid (SRNA) 1 | State Registered Nurse Aid | Provided nail care to Resident #6 and described nail care procedures |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed regarding nail care oversight and procedures |
| Director of Nursing | Director of Nursing | Conducted audits, provided education on nail care, and interviewed about facility practices |
| Administrator | Administrator | Interviewed regarding expectations for resident nail care and housekeeping standards |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning practices and handrail maintenance |
| Maintenance Assistant | Maintenance Assistant | Interviewed about black substance issue and handrail maintenance |
| Assistant Director of Maintenance | Assistant Director of Maintenance | Interviewed about handrail conditions and maintenance responsibilities |
| Restorative Nurse 1 | Restorative Nurse | Interviewed about loose handrails and resident safety concerns |
| Housekeeping Manager | Housekeeping Manager | Interviewed about cleaning schedules and black substance observations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 30, 2021
Visit Reason
The inspection was conducted based on complaints regarding failure to conduct timely comprehensive annual assessments and failure to provide appropriate treatment and care according to physician orders, specifically related to diabetic care and monitoring.
Findings
The facility failed to complete a required annual Minimum Data Set (MDS) assessment for one resident and failed to monitor and treat another resident's diabetes and vital signs appropriately, resulting in immediate jeopardy to resident health and safety. The facility did not follow professional standards for diabetic care, including monitoring blood glucose and vital signs as ordered, and failed to document and implement proper care plans and monitoring protocols.
Complaint Details
The complaint investigation revealed failure to complete timely annual assessments and failure to monitor and treat a diabetic resident properly, leading to immediate jeopardy. Immediate Jeopardy was identified on 07/16/2021 and removed on 07/21/2021 after corrective actions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to conduct a comprehensive annual assessment within the required timeframe for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, including failure to monitor blood glucose and vital signs for a diabetic resident, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents sampled: 22
Blood glucose level: 26
Blood glucose level: 300
Blood glucose level: 256
Blood pressure readings: 4
Vital signs monitoring frequency: 4
Immediate Jeopardy removal date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Named in failure to monitor and document blood glucose and vital signs for Resident #283 |
| Director of Nursing | DON | Monitored MDS assessments and acknowledged staff training deficiencies related to diabetic care |
| Administrator | Relied on MDS staff and DON for assessments and acknowledged expectations for diabetic care | |
| Physician #1 | Physician | Resident's physician who stated expectations for monitoring diabetic resident's blood glucose and vital signs |
| MDS Nurse #1 | MDS Nurse | Responsible for completing MDS assessments; missed annual assessment for Resident #1 |
| Social Services Director | SSD | Completed audits on baseline care plans for new admissions |
| Pharmacist | Provided expectations for monitoring diabetic residents and medication administration |
Inspection Report
Routine
Deficiencies: 4
Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, equipment safety, and overall facility environment at Cumberland Nursing and Rehabilitation Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper catheter care to prevent urinary tract infections, accurate administration of enteral nutrition per physician orders, and ensuring essential mechanical equipment was in safe working condition. Specific issues included improper storage of reusable resident equipment, catheter drainage bags touching the floor, failure to increase tube feeding as ordered, and a persistent leak under the dishwasher sink causing water overflow.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain a safe, clean, homelike environment by improperly storing reusable resident equipment such as bedpans and basins uncovered and unlabeled on the bathroom floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care; Resident #66's urinary catheter drainage bag was observed dragging on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure administration of enteral nutrition was consistent with physician orders for Resident #187; tube feeding was not increased as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep all essential equipment working safely; a leak under the dishwasher sink caused water to overflow into the kitchen and storage room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 19
Residents affected: 1
Residents affected: 1
Bathrooms inspected: 7
Tube feeding rate ordered: 65
Tube feeding rate observed: 30
Weight (pounds): 121
Weight (pounds): 118.4
Weight (pounds): 120.6
Water volume: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding storage policy and catheter care expectations |
| Wound Care/Infection Control Nurse | Infection Control Nurse | Interviewed regarding storage of reusable equipment and catheter care monitoring |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding handling of improperly stored equipment |
| Admissions Coordinator | Admissions Coordinator | Interviewed regarding monitoring of resident rooms and bathrooms |
| State Registered Nurse Aide #2 | State Registered Nurse Aide | Interviewed regarding catheter bag care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding tube feeding administration and documentation |
| Unit Coordinator | Unit Coordinator | Interviewed regarding documentation of tube feeding amounts |
| Dietary Employee #1 | Dietary Employee | Interviewed regarding water overflow from dishwasher sink |
| Dietary Employee #2 | Dietary Employee | Interviewed regarding emptying pan under dishwasher sink |
| Dietary Manager | Dietary Manager | Interviewed regarding work order and maintenance efforts to fix leak |
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