Wetumpka Health and Rehabilitation, LLC

Inspectors wroteBased on a test tray observation, interview, medical record review, and review of the facility's policies for Food Preparation Guidelines and Food Taste Test; the facility failed to ensure meals, other than pureed meals, were served at an acceptable warm temperature for lunch on 12/06/2023. This had the potential to affect 110 of 113 residents receiving meals from the facility's kitchen. This also affected two residents who said hot food was served cold, Resident Identifier (RI) #30 and RI #85.

Inspectors wroteBased on observation; interview; the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility's policies for Leftover Food Storage and Use, Dish Machine Sanitization, Food Cooking and Serving Temperatures, Food Preparation Guidelines, Cleaning of Miscellaneous Equipment and Utensils, Calibrating and Sanitizing Thermometers, Cleaning Schedules, and Insect and Rodent Control; the facility's food holding temperature record, reports from the facility's dishmachine service provider; and facility work order #954; the facility failed to ensure: [...]

Inspectors wroteBased on observations, interviews, review of the the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and review of the facility's policies for Garbage and Refuse and Insect and Rodent Control, the facility failed to ensure the garbage dumpster was closed, the grease refuse container was closed, the grease refuse container was not leaking, and the dumpster area was not littered with food-related trash and other items. This affected one of one garbage dumpster and one of one grease refuse container; and had the potential to affect 114 of 114 residents in the facility.

Inspectors wroteBased on observations, interviews and review of a facility policy titled, Resident Environmental Quality, the facility failed to ensure an end cap on a hand rail on one hallway was not missing; six air conditioner vents were free of dried dustlike condensations; five ventilation returns were free of dust and dried condensations that were dark in color; the corner trim was not missing and exposing nails at a nurses' station; and one fire extinguisher box was free of a brown colored substance. These deficient practices were observed during the survey and affected three of the six halls at the facility.

Inspectors wroteBased on an interview, review of Facility Reported Incidents (FRIs) received by way of the Alabama Department of Public Health Online Incident Reporting System and review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident /Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure the five (5) day investigation reports were submitted to the State Agency (SA) within the required timeframe after the initial reports were received. This affected six of 12 months of FRIs received by the State Agency in 2022.

Inspectors wroteBased on an interview, review of the facility's Non-Controlled Medication Destruction Records, and review of a facility policy titled, Non-Controlled Medication Destruction, the facility failed to ensure destruction dates and required signatures were on the non-controlled medication destruction sheets. This deficient practice affected non-controlled medication destruction sheets reviewed for one of 12 months in 2022, two of 12 months in 2023; and 12 non-controlled medication destruction sheets with no destruction dates or signatures.

Inspectors wroteBased on interviews, record review and review of facility policies titled, Change of Room or Roommate and Change in Medical Condition of Resident/Guest(s), the facility failed to: 1) notify the sponsor of Resident Identifier (RI) #265 when RI #265 was placed in a different room after returning to the facility after an emergency room (ER) visit on 02/13/2023, 2) ensure RI #9's Medical Doctor (MD) and sponsor were notified when RI #9 attempted to leave the facility on 07/14/2023, 3) notify the sponsor when RI #9 was sent to the hospital on [DATE]; and 4) notify the MD and sponsor when RI #9 missed a dialysis appointment on 11/25/2023. These deficient practices had the potential to affect RI #9 and RI #265, two of 37 sampled residents.

Inspectors wroteBased on interviews, record review and review of a facility policy titled, Pre- admission Screening for Mental Retardation and Mental Illness, the facility failed to: 1) ensure a new Level 1 was completed when Resident Identifier (RI) #59 was identified to have a new diagnosis of Anxiety on 03/27/2021; and 2) resubmit a Level 1 Preadmission Screening and Resident Review (PASRR) for Resident Identifier (RI) #64 upon readmission to the facility on [DATE], with new diagnoses of Post-traumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD). This deficient practice had the potential to affect RI #'s 59 and 64, two of six residents reviewed for PASRRs.

Inspectors wroteBased on observations, interview, resident record review, and review of a facility policy titled, Oxygen Administration, the facility failed to ensure a physician order was obtained for Resident Identifier (RI) #314's oxygen use. This deficient practice had the potential to affect RI #314, one of three residents sampled for respiratory care.

Inspectors wroteBased on interviews, record review and review of a facility policy titled, Pressure Injury, the facility failed to ensure treatments were provided to Resident Identifier (RI) #265's Stage I sacrum pressure ulcer as ordered by the physician. This deficient practice affected RI #265, one of five sampled residents reviewed for pressure ulcers.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled, Hemodialysis Care, the facility failed to ensure Resident Identifier (RI) #9 received care and services related to dialysis when RI #9 missed a dialysis appointment on 11/25/2023. This deficient practice affected RI #9, one of one resident sampled for dialysis care and services.

Inspectors wroteBased on an observation, interviews, and review of a facility policy titled, Storage of Medications and Biologicals, the facility failed to ensure Resinol (a medicated ointment typically used for itch relief and skin rashes) was stored in the original container in Resident Identifier (RI) #9's room. This had the potential to affect RI #9, one of 23 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled, Standard Precautions, the facility failed to ensure Certified Nursing Assistant (CNA) #12, did not create the potential for cross-contamination when she wiped feces from the floor with a dry towel and failed to use an appropriate disinfectant. Multiple staff were observed walking through the area after the feces was removed and before the floor was disinfected. This was observed on 12/05/2023. This deficient practice had the potential to affect one unit of the facility.

Inspectors wroteBased on an observation, interviews, review of the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility work order # (number) 953, the facility failed to ensure the Walk-in Cooler had an interior push handle on the door for emergency exit. This affected one of two walk-in food cooling units in the facility's kitchen.

Inspectors wroteBased on interviews, the facility's Meal Tray Service Schedule, and the facility's policy for Master Meal Schedule, the facility failed to ensure no more than 14 hours were scheduled between the service of Supper and the service of the Breakfast meal times. This had the potential to affect 113 of 113 residents receiving meals from the facility's kitchen.

Inspectors wroteBased on observation, interviews and a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure plates were allowed to air dry before stacking them during the lunch meal on 4/25/19. This deficient practice had the potentials to affect all 112 residents receiving meals from the dietary department.

Inspectors wroteBased on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #52 was not coded as having a Foley Catheter on his/her Quarterly Minimum Data Set (MDS) assessment, dated 02/18/19; and 2) RI #114's Discharge MDS assessment, dated 03/20/19, identified RI #114 as being discharged to another facility. These deficient practices affected RI #'s 52 and 114, two of 31 sampled residents whose MDS assessments were reviewed. Findings Include: 1) RI #52 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of Spinal Stenosis. A review of RI #52's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 02/18/19, assessed RI #52 as having a Brief Interview for Mental Status (BIMS) score of 13, indicating RI #52 was cognitively intact. RI #52 was further assessed as having an indwelling catheter during this assessment period. [...]

Inspectors wroteBased on observations, interview, record review and review of a facility policy titled, BASELINE CARE PLAN PROTOCOL, the facility failed to ensure Resident Identifier (RI) #163 had a baseline care plan addressing the use of his/her nebulizer treatments. This deficient practice affected RI #163, one of two sampled residents whose baseline care plans were reviewed.