Cumberland Health and Rehab

Inspectors wroteBased 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. The QAPI Committee did not identity that the facility did not have a policy and procedures in place to address resident vaping including where vaping was prohibited, safe storage of vape devices, and safe charging of the vape devices. [...]

Inspectors wroteBased 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. The staff member advised the daughter she needed to come to the facility to complete paperwork. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. These failures had the potential to affect all residents with a desire to vape or smoke in the facility. [...]

Inspectors wroteBased 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. The staff indicate RI #286 used his/her cell phone charger to charge the vape devices. [...]

Inspectors wroteBased on interviews, record review and the job description of the Director of Operations (Care Center), the Governing Body failed to provide oversite to ensure policies and procedures were developed and implemented for residents who vape, to address safe storage and safe charging. 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. The staff indicate RI #286 used his/her cell phone charger to charge the vape devices. [...]

Inspectors wroteBased on interviews, medical record review, and review of facility policies titled Behavioral Health Services and Comprehensive Care Plans the facility failed to ensure a behavioral health care plan was developed with person centered interventions for Resident Identifier (RI) #286 a resident with documented substance abuse and noncompliance of care. This affected RI #286 one of seven residents sampled for behaviors. These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176. Findings Include: Cross reference F741. The facility policy titled Comprehensive Care Plans with an effective date of 04/06/2015 and a last revised date of 02/09/2024 documented: . [...]

Inspectors wroteBased on interviews and a review of the Facility assessment dated [DATE], the facility failed to ensure substance abuse training was provided to staff. This deficient practice affected Resident Identifier (RI) #286 one of seven residents sampled for behaviors.

Inspectors wroteBased on interviews, record review and a review of the Facility Assessment, the facility failed to ensure the facility assessed addressed substance abuse, smoking and vaping. The facility's most current Facility assessment dated [DATE] did not identify the need for staff competencies regarding substance abuse. This deficient practice had the potential to affect 86 of 86 residents. These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176.

Inspectors wroteBased on interviews, residents' medical records, and the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manuals, the facility failed to ensure Section J of Resident Identifier (RI) #80 and RI #286's admission Minimum Data Set (MDS) assessments were accurately coded to reflect tobacco use during the assessment period. This had the potential to affect two of 20 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, interviews, record review and a facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #67's nebulizer mask was stored in a covered plastic bag on 05/29/2024 and 05/30/2024. This deficient practice affected RI #67 one resident sampled for respiratory care. Finding Include: A review of a facility policy titled, Oxygen Administration with an effective date of 05/2024 revealed: Policy: Oxygen is administered to resident who need it, consistent with professional standards of practice .Policy Explanation and Compliance Guidelines: 5 .d. Keep .devices covered in plastic bag when not in use . RI #67 was admitted to the facility on [DATE] with a diagnosis of Hypertensive Heart Disease with Heart Failure. RI #67's Physician Orders for May 2024 revealed: [...]

Inspectors wroteBased on record review, staff interviews, review of the United States (U.S.) Food and Drug Administration, FDA Drug Safety Communication, and review of the facility policy titled Medication Administration, the facility failed to ensure a Certified Nursing Assistant (CNA) #19 did not administer her personal prescription of Klonopin 0.5 milligram (mg) to Resident Identifier (RI) #286. This deficient practice was cited as a result of the investigation of a Facility Reported Incident AL00047176.

Inspectors wroteBased on observations, interviews, a review of the 2017 FOOD CODE, and the facility policy titled: Low Temperature Dishmachine, the facility failed to ensure the water temperatures reached a minimum required wash water temperature of 120 to 125 degrees F during ten of eleven cycles observed. This had the potential to affect all 83 residents for whom food was prepared and served at the time of this survey. Findings Included: The 2017 Food and Drug Administration Food Code, regulation 4-501.110(B) Mechanical Warewashing Equipment, Wash Solution Temperature mandates the following: The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than . 120 degrees F (Fahrenheit). The facility policy titled: Low Temperature Dishmachine (undated) states: [...]

Inspectors wroteBased on observation, interview, medical record review, and the facility's policy titled, Perineal Care, the facility failed to ensure nursing staff cleaned front to back while providing perineal care to Resident Identifier (RI) #24. This affected one of one sampled resident observed during incontinence care. Findings Include: A review of the facility's policy titled, Perineal Care with a Review/Revision Date of 5/10/18 revealed; . PURPOSE: To maintain cleanliness, promote comfort, prevent infections and skin breakdown . I. Policy Perineal care will be provided daily and as indicated. III. Procedure for female: . K. Using a washcloth with perineal cleanser or soap and water, separate labia using one hand and bathe with the other hand using gentle downward swipes from front to back. [...]

Inspectors wroteBased on observation, interview, medical record review. and a review of the facility's policy titled, Hand Hygiene, the facility failed to ensure nursing staff washed her hands; 1. Before and after touching the resident, 2. before putting on and taking off gloves, 3. before leaving the resident's room to get more supplies, 4. after cleaning the perineum and before touching clean items and items in the resident's room while performing incontinence care on Resident Identifier (RI) #24. This affected one of one resident's observed for incontinence care. A review of the facility's policy titled, Hand Hygiene, with a Revision Date of 03/2018, revealed: . PURPOSE: Proper hand hygiene will improve the health of healthcare workers, patients, volunteers and visitors by decreasing the transmission of infectious agents. POLICY: . 3. Perform hand hygiene: a. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1. assure the facility followed correct manual dishwashing procedures per chemical distributors technical data sheet (i.e. chemical concentration in the manual dishwashing was effective by testing/documenting the water temperature in the final rinse sink when using the chemical Quaternary Ammonia). 2. assure hot foods were maintained at 135 degrees Fahrenheit (F) or above when served from the tray line as evidenced by documentation. 3. assure food (ice cream) received frozen, was maintained frozen during storage, 4. assure the PM [NAME] practiced proper handwashing/glove change when going from touching potentially contaminated objects such as (soiled cloth hot pad, equipment (lid cover of hot plate storage, on/off dial of range top and lid covers from dry storage). 5. [...]

Inspectors wroteBased on observation, interviews and review of a facility policy titled, Medication Administration, the facility failed to ensure a licensed nurse checked placement of Resident Identifier (RI) #11's gastrostomy tube prior to medication administration. This affected RI #11, one of one residents observed for medication administration observation via gastrostomy tube. Findings Include: A review of a facility policy titled, Medication Administration with a Last Revised date of 03/2016, revealed: .7. MEDICATION GIVEN THROUGH FEEDING TUBE A. Licensed nurses will administer per gastric tube as ordered by physician .vii. Check for proper tube placement . RI #11 was readmitted to the facility on [DATE], with diagnoses including Encounter for Attention to Gastrostomy and Diaphragmatic Hernia Without Obstruction or Gangrene. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure a licensed nurse did not place a bag containing a soiled brief and gloves and a bag containing soiled linens on a fall mat beside Resident Identifier (RI) #59's bed. This affected RI #59, one of one residents observed for incontinence care. Findings Include: RI #59 was readmitted to the facility on [DATE], with diagnoses including Unspecified Quadriplegia. On 07/26/18 at 8:48 a.m., during incontinence care observation, Employee Identifier (EI) #4, Registered Nurse (RN), was observed placing a bag containing soiled linen and a bag containing a soiled brief, wipes and gloves on the fall mat beside RI #59's bed. On 07/26/18 at 12:44 p.m., an interview was conducted with EI #2, RN/Staff Development/Infection Control Coordinator. [...]