Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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 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.
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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.
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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 | — | 1 | 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 August 2026) and official state health department websites.