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🔎 Cumberland Pointe Health Campus

Inspection Results


Inspection Overview

Cumberland Pointe Health Campus has been cited for a total of 37 deficiencies since we began saving each survey.

In Indiana, the average facility has **42.94 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-04-25
Correction Date: 2025-01-24
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-06-10
Correction Date: 2024-07-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-03-07
Correction Date: 2023-04-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2022-10-04
Correction Date: 2022-10-18
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-02-03
Correction Date: 2021-02-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2021-01-14
Correction Date: 2021-02-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2020-08-26
Correction Date: 2020-09-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2020-08-26
Correction Date: 2020-09-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: C

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-02-28
Correction Date: 2020-03-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2019-01-09
Correction Date: 2019-02-08
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**