Cumberland Healthcare Center

According to the complaint on 5/26/26 the complainant reported they had no hospital bed yet. An interview with SW #5 on 5/28/26 at 11:44 AM revealed she called the insurance company and they denied giving the resident an electric wheelchair, however there was no documentation of this in the medical record.

Although there was an order from the attending physician on 5/4/26 for a mechanical lift, she reported she did not attempt to get a mechanical lift for the resident because the resident was efficient with the slide board so there was no need for a mechanical lift.

There was no documentation in the medical record that this was discussed with the attending physician or the IDT.

She reported that the resident was approved for the hospital bed, and this information was sent to the medical supply vendor.

She remembered an Adult Protective Services employee called post discharge regarding this resident, and they were referred to the primary care physician to get home health services.

She failed to document this interaction in the medical record.

On 5/28/26 at 12:49 PM an interview with the DON revealed the resident had been admitted to the facility in November of 2025 after his/her left leg was amputated and then was discharged home.

She reported that because the resident had been home and had no issues it was questionable whether the resident needed the hospital bed.

Although it was written in the discharge summary by NP #4 that the resident needed a bed.

The DON stated that the resident had a functional bed at home the first time s/he was discharged home and she was not sure what would have changed. It was further determined that the resident had one amputation the first time they went home and then had a double amputation when discharged the second time.

She agreed that this would change the resident's level of function in the home, however confirmed that facility staff failed to conduct a home visit to ensure the resident had all the necessary adaptations in place.

The concerns were reviewed with the Nursing Home Administrator and the DON.

215055 05/28/2026

Cumberland Healthcare Center 512 Winifred Road Cumberland, MD 21502

during 1 random observation of nursing unit 1.

The findings include: 1) On 05/19/26 at 11:04 AM

back his/her medication yet.

The resident responded no and Aid #2 reassured the resident that the nurse was aware and would be back shortly.

The resident was observed to be sitting up in bed, pursed lip breathing with use of accessory muscles and appeared restless.

The resident was asked what s/he needed and s/he reported s/he had requested his/her inhaler because s/he was having trouble breathing.

The resident reported they were unsure of the time it was requested. An interview with Aid #9 at 11:11 AM revealed about 5 minutes ago she had reported to Certified Medicine Aid #13 that the resident was asking for their inhaler because they were having trouble breathing. On 5/19/26 at 11:16 AM the surveyor stopped by and asked Resident #14 if the nurse had come in yet and the resident reported no. CMA #13 was observed in the hallway stocking the medication cart. On 5/19/26 at 11:17 AM during an interview with CMA #13 she reported that when a resident requested a PRN (as needed medication) she was able to administer some without the nurse assessing the resident first.

She stated that this was the case with a rescue inhaler.

When asked if she was aware that Resident #14 had requested their rescue inhaler, she stated she was aware and had not been back to check the resident.

She stated she was stocking her medication cart while waiting for the time the resident's inhaler was due because it had not been quite 3 hours.

She stated Resident #14 would become anxious when it was close to the time for the inhaler and start asking for it early.

When asked if she had reported this to the nurse she stated she had not. A medical record review for Resident #14 on 5/19/26 at 11:44 AM revealed the resident medication administration report.

The documentation revealed the resident was ordered a rescue inhaler to be given every 3 hours for shortness of breath and wheezing and the last time the resident was given the inhaler was at 6:38 AM approximately 4 hours and 20 minutes prior to asking for the medication around 11:00 AM (the exact time was unknown). At 11:22 AM CMA #13 had documented a late entry administration of the rescue inhaler for 11:05 AM, which was not accurate as this was when the observation was made and before the interview with the CMA in which she reported she had not administered the medication.

Further review of the progress notes revealed that a nurse had not assessed the resident prior to administering the medication. An interview with the Director of Nursing (DON) on 5/19/26 at 1:26 PM revealed that PRN medication were allowed to be administered by the CMA after a nurse assessed the resident and gave their approval.

She was made aware that this had not been done for Resident #14 and made aware of the delay in treatment.

She reported that it was not acceptable practice because the nurse should have assessed the resident's lung sounds prior to the administration.

When asked if the facility had a standard of professional practice manual that staff could refer to she reported they had not established one.

She was made aware of the late entry administration by CMA #13 indicating that she gave the resident the medication earlier than she had.

The DON responded that she would find out what happened and report back to the surveyor.

The DON reported back on 5/20/26 at 2:44 PM that CMA #13 had opened the PRN order when the aid told her that Resident #14 was requesting the medication.

Then when she signed it off it came back as a late entry for 11:05 AM when she had initially opened the order.

The DON reported that she educated the CMA that orders were not to be opened until she was ready to administer the medication to avoid this from reoccurring.

215055 05/28/2026

Cumberland Healthcare Center 512 Winifred Road Cumberland, MD 21502

doesn't offer ice and heat for pain management.

She reported that when she had not heard back from

able to get the orders signed off.

She was unable to recall the timing of these events and failed to

the resident, around 1:00 AM, the resident was upset that it was only 1 tablet and not 2 tablets.

She reported she attempted to explain this to the resident but then the resident stated s/he was going to file a grievance against her so she called her supervisor.

She reported the supervisor took the discharge paperwork back to the resident to show the resident what had been ordered.

She reported she had not called the hospital to confirm that the resident should get 1 or 2 tablets. An interview with the supervisor, Registered Nurse (RN) #8 on 5/26/26 at 4:03 PM revealed she went to the resident to listen to their concerns and then attempted to show the resident the orders on the discharge instructions.

She reported she had not called the hospital to confirm the orders, offer any nonpharmacological interventions, or educate the resident that it was ok to take the Tylenol until the Percocet was signed off and available to give them.

The concerns were reviewed with the Director of Nursing (DON) on 5/27/26 at 11:49 AM.

She reported that if the resident was admitted at 8:30 PM then the assigned nurse was probably passing medications to their assigned residents at that time, and this would cause a delay with admission orders.

She agreed that the nurses should have clarified the Percocet order for the resident versus trying to convince the resident what the discharge orders were.

She stated that they should have offered the nonpharmacological interventions even though she felt that the resident would not have accepted them.

The DON reported they had not addressed the concerns with the orders not being signed off by the physician at the time of admission and 1 1/2 hours later the nurse was unable to administer the medications as ordered although she reported it was a known issue with their providers failing to respond to the messages timely.

The concerns were reviewed with the Nursing Home Administrator on 5/28/26 at 8:47 AM.

215055 05/28/2026

Cumberland Healthcare Center 512 Winifred Road Cumberland, MD 21502

during the complaint survey.

The findings include: A treatment cart is a cart that has supplies to

nursing practice is to use this cart in the hallway to assemble treatment supplies for a resident, but does not go into the resident rooms for infection control purposes, just as medication carts and linen carts. On 5/19/26 at 9:59 AM a resident fell in their room on the second-floor nursing unit. In response Licensed Practical Nurse (LPN) #14 took the treatment cart with supplies laying on the top, into the resident's room between the bed and the wall and shut the door.

When the nurse returned to the nurses' station on 5/19/26 at 10:07 AM, with the treatment cart she was interviewed.

She reported that they do not normally take a treatment cart into the resident's rooms for infection control reasons.

She stated she took the cart in because she was concerned about the resident's blood sugar because the resident was diaphoretic when she was found on the floor.

She stated that because of this, she [the nurse] became anxious and inadvertently taken the cart in the room. An interview with the Infection Preventionist on 5/27/26 at 11:15 AM revealed it was not the practice of the facility to take treatment carts into the residents' rooms.

She stated that this was unacceptable and the nurse was educated after surveyor intervention.