Cycle 1
Health 2024-06-03 · Fire 2024-06-03
12 health deficiencies
Top issue: Administration (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Bridgeport, AL
Cumberland Health And Rehab
2-star overall rating with 1-star inspections with abuse icon flag with $238,745 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
47065 Al Highway 277, Bridgeport, AL
(256) 437-7260
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Huntsville Hospital Health System
Operator or chain grouping
Approved since
1992-05-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,318
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.60
Composite VBP score used to determine payment impact.
Payment multiplier
1.0128
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.53
Baseline 20.17% · Performance 19.79% · Measure score 3.53 · Achievement 3.53 · Improvement 0.69
Healthcare-associated infections
7.47
Baseline 7.43% · Performance 5.60% · Measure score 7.47 · Achievement 7.47 · Improvement 7.01
Total nurse turnover
8.55
Performance 28.75% · Measure score 8.55 · Achievement 8.55 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.49
Baseline 3.91 hours · Performance 4.07 hours · Measure score 3.49 · Achievement 3.49 · Improvement 0.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.13% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 15.25% · Lower 95% interval 9.28% |
| Discharge to community | 42.65% |
50.57%
7.9 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 40.26% · Lower 95% interval 34.85% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 32 · Denominator 54 |
| Discharge mobility score | 53.7% |
50.94%
2.8 pts better
|
Numerator 29 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 0% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 0.89% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 112 |
| Staff flu vaccination coverage | 72.92% |
42%
30.9 pts better
|
Numerator 70 · Denominator 96 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 38 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 6 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.3%
8.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.4%
1.6 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.9% · Q3 4.7% · Q4 6.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.3%
0.7 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.0% · Q3 7.0% · Q4 1.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
24.9%
3.4 pts worse
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 27.6% · Q3 31.0% · Q4 23.4% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
22.8%
6.3 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 19.0% · Q3 15.2% · Q4 14.9% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.1% |
14.8%
7.3 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q3 4.3% · Q4 14.5% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
13.4%
3.5 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 14.3% · Q3 10.5% · Q4 19.0% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.3%
1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.9% · Q3 1.6% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
13.5%
14.6 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 30.3% · Q3 18.4% · Q4 24.5% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
5.7%
4.9 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
84.3%
12.8 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.8% · Q3 98.6% · Q4 96.8% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
11.5%
4.5 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.1%
0.6 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
80.3%
15.2 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
24.5%
7.2 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.0% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-29 · Fire 2019-08-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-07-26 · Fire 2018-07-26
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-02
E · Potential for more than minimal harm
2019-08-29
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-10-08
D · Potential for more than minimal harm
2019-08-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-08
D · Potential for more than minimal harm
2019-08-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-08
F · Potential for more than minimal harm
2018-07-26
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-09-04
F · Potential for more than minimal harm
2018-07-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-07-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-07-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-09-04
Inspection history
Recent health citations
L · Immediate jeopardy
2024-06-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-02
K · Immediate jeopardy
2024-06-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-02
K · Immediate jeopardy
2024-06-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-02
K · Immediate jeopardy
2024-06-03
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-07-02
J · Immediate jeopardy
2024-06-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-02
J · Immediate jeopardy
2024-06-03
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-03
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-03
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-02
F · Potential for more than minimal harm
2019-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-23
D · Potential for more than minimal harm
2019-08-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-09-23
D · Potential for more than minimal harm
2019-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-23
F · Potential for more than minimal harm
2018-07-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-07-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-04
Penalties and ownership
What sits behind the stars
$238,745
2024-06-03
Fine
Fine · fine $238,745
Fine
Ownership
Anderson, John
Operational/Managerial Control · Individual
Anderson, John
Corporate Officer · Individual
Anderson, John
W-2 Managing Employee · Individual
Bentley, Philip
Corporate Officer · Individual
Carrier, John
Operational/Managerial Control · Individual
Carrier, John
W-2 Managing Employee · Individual
Carter, Clinton
Corporate Officer · Individual
Matthews Jr, Robert
Corporate Officer · Individual
Samz, Jeffrey
Corporate Officer · Individual
Samz, Jeffrey
W-2 Managing Employee · Individual
The Health Care Authority Of The City Of Huntsville
5% Or Greater Direct Ownership Interest · Organization
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#3
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