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Cumberland Manor Nursing Center
4343 ASHLAND CITY HWY
Nashville, TN 37218
(615) 726-0492
General
Ratings
Deficiencies
Resident Stats
Staff Stats
| Certified Beds: | 124 |
| Number of Residents: | 118 |
| Percent of Occupied Beds: | 95% |
| Sprinkler Status: | Fully Sprinklered |
| Program Participation: | Medicare and Medicaid |
| Type of Ownership: | For profit - Corporation |
| Located Within a Hospital? | No |
| Multi Nursing Home Ownership? | No |
| Resident and Family Councils? | Resident |
| Continuing Care Retirement Community? | No |
| Quality Indicator Survey? | No |
| Special Focus Facility? | Yes |
| Overall: |  |
| Health Inspection: | |
| Nurse Staffing: |  |
| Quality Measures: |  |
| RN Only: | |
| Date | Type | Category | Deficiency | Scope | Level of Harm | Date of Correction |
| 20071113 | Health | Quality Care Deficiencies | Give professional services that meet a professional standard of quality. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Quality Care Deficiencies | Give professional services that follow each resident's written care plan. | Isolated | Immediate jeopardy to resident health or safety | 20080103 |
| 20071113 | Health | Quality Care Deficiencies | Give each resident care and services to get or keep the highest quality of life possible. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Resident Rights Deficiencies | Keep each resident's personal and medical records private and confidential. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Mistreatment Deficiencies | Protect each resident from all abuse, physical punishment, and being separated from others. | Isolated | Actual harm | 20080103 |
| 20071113 | Health | Mistreatment Deficiencies | 1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Isolated | Immediate jeopardy to resident health or safety | 20080103 |
| 20071113 | Health | Resident Rights Deficiencies | Provide care in a way that keeps or builds each resident's dignity and self respect. | Isolated | Actual harm | 20080103 |
| 20071113 | Health | Resident Rights Deficiencies | Listen to the resident or family groups or act on their complaints or suggestions. | Pattern | Immediate jeopardy to resident health or safety | 20071116 |
| 20071113 | Health | Quality Care Deficiencies | Provide social services for related medical problems to help each resident achieve the highest possible quality of life. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Environmental Deficiencies | Provide needed housekeeping and maintenance. | Pattern | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | Make a complete assessment that covers all questions for areas that are listed in official regulations. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | Do a new assessment after any major change in a resident's physical or mental health. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | Do an assessment of the resident every year. | Isolated | Actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | Check and update (if needed) each resident's assessment every 3 months. | Isolated | Actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Resident Assessment Deficiencies | 1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Environmental Deficiencies | Make sure that the nursing home area is free of dangers that cause accidents. | Isolated | Immediate jeopardy to resident health or safety | 20080103 |
| 20071113 | Health | Pharmacy Service Deficiencies | Make sure that residents are safe from serious medication errors. | Isolated | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Quality Care Deficiencies | Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Pattern | Immediate jeopardy to resident health or safety | 20071116 |
| 20071113 | Health | Administration Deficiencies | post nurse staffing information. | Widespread | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Nutrition and Dietary Deficiencies | Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Pattern | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Pharmacy Service Deficiencies | Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | Pattern | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Pharmacy Service Deficiencies | At least once a month, have a licensed pharmacist check the drugs that each resident takes. | Pattern | Minimal harm or potential for actual harm | 20080103 |
| 20071113 | Health | Administration Deficiencies | Be administered in a way that leads to the highest possible level of well being for each resident. | Pattern | Immediate jeopardy to resident health or safety | 20071116 |
| 20071113 | Health | Administration Deficiencies | Follow all laws and professional standards. | Pattern | Minimal harm or potential for actual harm | 20080103 |
| 20090730 | Health | Resident Assessment Deficiencies | 1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. | Isolated | Minimal harm or potential for actual harm | 20090812 |
| 20090730 | Health | Quality Care Deficiencies | Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Isolated | Minimal harm or potential for actual harm | 20090812 |
| 20090730 | Health | Resident Rights Deficiencies | Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Isolated | Minimal harm or potential for actual harm | 20090812 |
| Value | Notes | |
| Percent of long-stay residents given influenza vaccination during the flu season: | 97 | |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination: | 94 | |
| Percent of long-stay residents whose need for help with daily activities has increased: | 9 | |
| Percent of long-stay residents who have moderate to severe pain: | 3 | |
| Percent of high-risk long-stay residents who have pressure sores: | 6 | |
| Percent of low-risk long-stay residents who have pressure sores: | 1 | |
| Percent of long-stay residents who were physically restrained: | 14 | |
| Percent of long-stay residents who are more depressed or anxious: | 3 | |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder: | 45 | |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder: | 9 | |
| Percent of long-stay residents who spend most of their time in bed or in a chair: | 6 | |
| Percent of long-stay residents whose ability to move about in and around their room got worse: | 4 | |
| Percent of long-stay residents who had a urinary tract infection: | 18 | |
| Percent of long-stay residents who lose too much weight: | 8 | |
| Percent of short-stay residents given influenza vaccination during the flu season: | 95 | |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination: | 86 | |
| Percent of short-stay residents who have delirium: | 4 | |
| Percent of short-stay residents who had moderate to severe pain: | 17 | |
| Percent of short-stay residents who have pressure sores: | 12 | |
| # of Residents: | 118 |
| # RN Hours per Resident: | 0.45 |
| # LPN Hours per Resident: | 1.07 |
| # CNA Hours per Resident: | 1.95 |
| Total Staff Hours per Resident: | 1.52 |
