Cycle 1
Health 2023-12-07 · Fire 2023-12-07
15 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wetumpka, AL
Wetumpka Health And Rehabilitation, LLC
1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1825 Holtville Road, Wetumpka, AL
(334) 567-5131
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1967-07-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 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
0.54
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,838
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.85
Baseline 20.80% · Performance 19.19% · Measure score 4.85 · Achievement 4.85 · Improvement 3.78
Healthcare-associated infections
0
Baseline 6.53% · Performance 7.94% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.09
Performance 46.96% · Measure score 4.09 · Achievement 4.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.69
Baseline 4.32 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 11.03% · Lower 95% interval 8.1% |
| Discharge to community | 47.44% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 42.11% · Lower 95% interval 38.94% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.71% |
95.27%
5.6 pts worse
|
Numerator 61 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 39.02% |
53.69%
14.7 pts worse
|
Numerator 16 · Denominator 41 |
| Discharge mobility score | 29.27% |
50.94%
21.7 pts worse
|
Numerator 12 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 4 · Denominator 68 · Adjusted rate 5.41% |
| Healthcare-associated infections requiring hospitalization | 7.94% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 8.64% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 115 |
| Staff flu vaccination coverage | 14.57% |
42%
27.4 pts worse
|
Numerator 22 · Denominator 151 |
| Discharge function score | 39.02% |
56.45%
17.4 pts worse
|
Numerator 16 · Denominator 41 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · 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 | 95.5% |
94.8%
0.7 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.7% · Q3 1.9% · Q4 1.0% · 4Q avg 2.9% · 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 | 10.0% |
5.3%
4.7 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 16.0% · Q3 5.9% · Q4 3.2% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
24.9%
About the same
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 25.0% · Q3 25.0% · Q4 26.6% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
22.8%
2.7 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 23.4% · Q3 22.4% · Q4 27.8% · 4Q avg 25.5% · 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 | 21.4% |
14.8%
6.6 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 25.6% · Q3 2.9% · Q4 28.6% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
13.4%
0.8 pts worse
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.9% · Q3 3.8% · Q4 22.5% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.7% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.6%
2.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.8% |
13.5%
10.7 pts better
|
19.8%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.0% · Q3 1.0% · Q4 5.9% · 4Q avg 2.8% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.7%
2.1 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 10.7% · Q3 7.4% · Q4 7.6% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
84.3%
15.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.5%
0.9 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
2.1%
1.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
80.3%
17.8 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.6% |
24.5%
13.1 pts worse
|
23.9%
13.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.6% · Observed 33.7% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-27 · Fire 2022-01-27
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-04-25 · Fire 2019-04-25
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-17
E · Potential for more than minimal harm
2022-01-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-12-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-07
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 2024-01-11
F · Potential for more than minimal harm
2023-12-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-11
C · Minimal harm
2023-12-07
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-01-11
F · Potential for more than minimal harm
2019-04-25
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 2019-05-23
D · Potential for more than minimal harm
2019-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-23
D · Potential for more than minimal harm
2019-04-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-05-23
Penalties and ownership
What sits behind the stars
Ownership
Nhs Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Algarin, Lisa
Operational/Managerial Control · Individual
Baggett, Bryan
Operational/Managerial Control · Individual
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Berkadia Commercial Mortgage LLC
5% Or Greater Mortgage Interest · Organization
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Richburg, Julie
Operational/Managerial Control · Individual
Wetumpka Health Realty LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
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2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $182,968 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Montgomery Children's Specialty Center
Montgomery, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Charlton Place Rehab And Healthcare Center
Deatsville, AL
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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