Cumberland Health and Rehab

In the surveyor’s words

From the most serious findings on record at Cumberland Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF867Jun 3, 2024

  Based on record review, the facility policy, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to ensure the QAPI committee developed interventions, including training to systemically address protective measures following an incident of a visitor to resident sexual abuse that occurred on 12/21/2023. Further the facility failed to ensure QAPI Committee identified all causal factors and developed and implemented corrective action plan to systemically address factors related to Resident Identifier (RI) #286 keeping vape devices in his/her room. […]

• Immediate jeopardy, patternF600Jun 3, 2024

  Based on interviews, record review, review of a facility policy titled, Abuse, Exploitation and Neglect Prevention, Investigation and Reporting, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, review of the facility's investigative file, a review of the Incident/Offense Report, and the facility policy titled Medication Administration the facility failed to: 1) protect Resident Identifier (RI) #27 right to be free from sexual abuse perpetrator by a visitor. In late November or early December 2023 RI #27's daughter called the facility and informed them that a male visitor was upsetting RI #27 when he came to visit. RI #27's daughter said she did not want the male visitor visiting RI #27. […]

• Immediate jeopardy, patternF689Jun 3, 2024

  Based on record review, interviews, a Facility Reported Incident (FRI) received by the Alabama Department of Public Health, the U.S. (United States) Food and Drug Administration's article titled Tips to Help Avoid Vape Battery or Fire Explosions, the facility's form titled Safe Smoking Evaluation, and a facility policy titled Smoking Policy the facility failed to ensure: 1) a system was in place to ensure residents' safety while smoking 2) a system was developed and implemented to ensure electronic cigarettes or vape devices were stored and charged safely. RI #286 was admitted on [DATE], upon admission, RI #286's hospital discharge papers indicated that he/she was a daily smoker. The facility's activity log indicated that RI #286 went out to smoke at the facility beginning on 10/28/2023. […]

• Immediate jeopardy, patternF926Jun 3, 2024

  Based on record review, interviews, and a facility policy titled Smoking Policy the facility failed to develop and implement a smoking policy that defined vapes, storage of vapes, charging of vapes, where vapes were permitted, addressed noncompliance of vapes, provided instructions for the use of the facility's Smoking Safety Evaluation tool, and the development of person-centered care plans for residents with the desire to vape. This failure affected Resident Identifier (RI) #286, one of one resident sampled for vaping, and RI #25, RI #34, RI #48, and RI #80 who did not have care planned interventions to ensure their safety while smoking as indicated by their Smoking Safety Evaluation tool. […]

• Immediate jeopardy, isolatedF835Jun 3, 2024

  Based on interviews, record review, review of the Job Description of the Administrator, the facility failed to ensure policies and procedures were developed and implemented for residents who vape, to address safe storage, safe charging, and where vaping was permitted. On 03/04/2024 staff found multiple vapes devices in RI #286's room. Upon investigation, it was revealed that the Director of Nursing (DON) had found a vape in RI #286's room on two separate occasions weeks prior to 03/04/2023. Further staff revealed that RI #286 was found with vapes in his/her rooms on multiple other occasion and no actions were taken. Multiple staff indicated RI #286 would sleep with a vape device on his/her chest and would charge the devices at bedside. […]