Care and Rehab Cumberland: Fall Investigation Failures - WI
That gap is what a federal inspection, completed September 18, 2025, found at the facility. The complaint-driven survey identified one deficiency: the nursing home failed to conduct a thorough investigation into the fall, specifically by never interviewing or assessing other residents to determine whether the same aide had transferred them improperly, too.
The resident, identified in inspection records only as R1, had been admitted to the facility with a complicated medical picture. Palliative care. Atrial fibrillation. Congestive heart failure. Chronic kidney disease. A history of falling. And dementia, unspecified, with a cognitive assessment score of 8 out of 15, a range that indicates moderate impairment. R1 transferred with the assistance of one person, using a gait belt and a walker. That was the plan of care. That was what the aide was supposed to follow.
On the morning of the fall, the aide, identified in records as CNA C, was not following it.
The facility's own investigation notes confirm R1 was interviewed about the fall on August 24, 2025, the same day it happened. Staff verbally educated CNA C that day on safe handling of residents. Four days later, on August 28, the Director of Nursing, identified as DON B, sat down with CNA C and went further, providing written education about the Safe Handling of Residents policy, specifically the importance of using a gait belt and non-slip footwear.
The education happened. The documentation happened. What didn't happen was any inquiry into who else CNA C had been transferring, and whether those residents had been transferred safely.
The facility's own abuse prevention policy, last reviewed in May 2025, lays out what a thorough investigation looks like. The policy states that investigations may include, among other steps, interviewing other residents to determine if they have been abused or mistreated. The surveyor found no documentation that any other resident had been interviewed or assessed for past falls or potential neglect concerns related to CNA C and safe transfers. None.
When the surveyor asked DON B directly, on the morning of September 18, whether any other residents had been interviewed after R1's fall, DON B said no. DON B had not interviewed any other residents after identifying that CNA C had failed to follow the care plan during a transfer.
That answer is the center of the deficiency. The facility knew, within hours of the fall, that a certified nursing assistant had skipped two required safety measures while moving a fragile, cognitively impaired resident. They knew CNA C worked with other residents. They did not ask those residents whether anything similar had happened to them.
The question matters because of what the safety measures are actually for. A gait belt is a wide strap fastened around a resident's waist that gives a caregiver something firm to grip during a transfer. Without it, a caregiver assisting a resident who begins to lose balance has far less control. Non-slip footwear reduces the chance that a resident's feet slide out from under them the moment they bear weight. For someone with a history of falling, moderate dementia, heart failure, and kidney disease, a fall is not a minor inconvenience. It is a serious medical event with serious potential consequences.
CNA C was not following either precaution when R1 fell. The investigation that followed never established whether that was an isolated lapse or a pattern.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. That framing reflects the regulatory classification of what was found, not a judgment that the gap was trivial. A nursing home's investigation process exists precisely to catch patterns before they produce worse outcomes. When a facility skips the step of asking other residents whether they've been hurt, it cannot know what it missed.
Care and Rehab Cumberland's abuse prevention policy is explicit about this. The policy describes a systematic approach to protecting residents from abuse and mistreatment. It lists, as part of that system, the step of interviewing other residents. The facility reviewed that policy in May 2025, four months before the fall. The policy was current. The practice was not.
What the inspection record does not contain is any explanation from DON B for why the broader inquiry didn't happen. The surveyor's notes capture the admission that it didn't, but not the reasoning behind the decision. Whether DON B considered the step and concluded it wasn't warranted, or whether the step simply wasn't considered at all, the inspection report doesn't say.
What it does say is that by the time the surveyor arrived on September 18, nearly a month had passed since R1's fall. CNA C had been educated, twice. The written documentation was in order. And not one other resident had been asked whether CNA C had ever transferred them without a gait belt, without proper footwear, or in any way that felt unsafe or caused them to fall.
R1, with a BIMS score of 8 out of 15, has moderate cognitive impairment. The inspection notes indicate R1 was interviewed about the fall on the day it occurred. What R1 said during that interview, and what R1 was able to communicate, is not recorded in the inspection narrative. What is recorded is that the facility's investigation stopped with R1 and CNA C, and went no further.
The other residents at Care and Rehab Cumberland, whatever their cognitive status, whatever their transfer needs, whatever their history with CNA C, were never asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care and Rehab - Cumberland from 2025-09-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
CARE AND REHAB - CUMBERLAND in CUMBERLAND, WI was cited for violations during a health inspection on September 18, 2025.
That gap is what a federal inspection, completed September 18, 2025, found at the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.