Care And Rehab - Cumberland
Inspection Findings
F-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon
interview and policy review, the facility did not ensure a thorough investigation for 1 of 1 (Resident R1) resident reviewed for safety concerns.Resident R1 fell during an assist of 1 transfer with Certified Nursing Assistant (CNA) C without proper safety measures in place. Facility did not complete a thorough investigation when they did not interview or investigate for potential risk to other residents throughout the facility.This is evidenced by:The facility's policy and procedure for Abuse Prevention, last reviewed 05/2025, includes, in part: .The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of the policy is to use a systematic approach to the creating of a climate which encourages the protection of the right to be free from abuse. This will be done by:* 6. A thorough investigation of the allegation will be initiated. 7. The investigation may include, but not limited to:c. Interviewing other residents to determine if they have been abused or mistreated .Resident R1 was admitted to the facility on [DATE REDACTED] with the following diagnoses: palliative care, atrial fibrillation, congestive heart failure, unspecified dementia, chronic kidney disease, and history of falling. The Minimum Data set (MDS) dated [DATE REDACTED] indicates Resident R1 has a Brief Interview for Mental Status (BIMS) of 8/15 which indicates Resident R1 has moderate cognition impairment. Resident R1 transfers with assist of one, gait belt, and with walker. Surveyor reviewed investigation notes pertaining to Resident R1's fall incident that stated in part: Resident R1 interviewed about fall on 08/24/25. Facility Reported Incident (FRI) indicates CNA C was transferring Resident R1 from the bathroom to Resident R1's wheelchair and Resident R1 fell on [DATE REDACTED] at 6:44 AM. Resident R1 did not have a gait belt on or non-slip footwear per plan of care when the fall occurred. Staff verbally educated CNA C on 08/24/25 on safe handling of residents.
Director of Nursing (DON) B interviewed CNA C on 08/28/25 about Resident R1's fall and provided written education pertaining to Safe Handling of Residents policy and importance of using gait belt and non-slip footwear.Surveyor did not find any documentation that other residents were interviewed or assessed for any past falls or potential neglect concerns regarding CNA C and safe transfers. On 09/18/25 at 8:57 AM, Surveyor interviewed DON B and asked DON B if any other residents were interviewed after Resident R1's fall to inquire about potential other falls during CNA C transferring other residents and cares. DON B reported to Surveyor that DON B did not interview any other residents after identifying CNA C did not follow the care plan during a transfer. Surveyor did not find a thorough investigation completed to assess for other caregiver neglect concerns with other residents and CNA C.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
CARE AND REHAB - CUMBERLAND in CUMBERLAND, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CUMBERLAND, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CARE AND REHAB - CUMBERLAND or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.