CUMBERLAND VALLEY MANOR

Nursing Home Inspector

301 SOUTH MAIN STREET
BURKESVILLE, KY 42717
Cumberland County
Phone: 270-864-4315
Provider Number: 185270
Last Inspection: 08/09/2017

About the Nursing Home

Number of Beds: 84
Number of Residents: 78
Beds Available: 6
Percent Occupancy: 93%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

14

Facility
14

County
12

KY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

14

2017
9

2016
6

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/8/2017
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 9/8/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/8/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 9/8/2017
 

7/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 8/5/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 8/8/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 8/5/2016
 

5/7/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/12/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/12/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/14/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with 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 : Minimal 3 3/14/2017
 

6/4/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 6/11/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/20/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/20/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KY State Avg
Number of Residents 78 78.00 79.68
Registered Nurses 0.55 0.55 0.86
Licensed Practical / Vocational Nurses 0.67 0.67 0.87
Certified Nursing Assistants 2.81 2.81 2.40
Total Staff Hours 4.02 4.02 4.13

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KY State Avg%
of high risk long-stay residents with pressure ulcers 14 14 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 100 95
of long-stay residents experiencing one or more falls with major injury 5 5 3
of long-stay residents who have depressive symptoms 6 6 2
of long-stay residents who lose too much weight 12 12 7
of long-stay residents who received an antianxiety or hypnotic medication 42 42 31
of long-stay residents who received an antipsychotic medication 31 31 19
of long-stay residents who self-report moderate to severe pain 2 2 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 22 21
of long-stay residents whose need for help with daily activities has increased 11 11 16
of long-stay residents with a catheter inserted and left in their bladder 3 3 2
of long-stay residents with a urinary tract infection 12 12 4
of low risk long-stay residents who lose control of their bowels or bladder 46 46 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 84
of short-stay residents who had an outpatient emergency department visit 15 15 14
of short-stay residents who newly received an antipsychotic medication 5 Not Available   59
of short-stay residents who self-report moderate to severe pain 7 5 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 98 7 16
of short-stay residents who were rehospitalized after a nursing home admission 32 98 83
of short-stay residents who were successfully discharged to the community 42 32 22
of short-stay residents with pressure ulcers that are new or worsened 7 42 46