Wellington Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received food prepared in a form designed to meet individual needs for 1 (Resident #1) of 5 residents reviewed for dietary needs. The facility failed, on the evening of 04/30/26, to serve Resident #1 a mechanically soft meal as ordered by her physician. The noncompliance was identified as PNC. The IJ began on 04/30/26 when Resident #1 was served the wrong texture of meal and choked on a meatball. The facility had corrected the noncompliance before the investigator entered the facility. This failure could place residents at risk of aspiration, choking, and/or weight loss. It resulted in Resident #1 chokeding on a meatball and requiring the Heimlich maneuver to restore her ability to breathe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore hair restraints and beard guards while in the kitchen. B. Ensure stored and cooked food was properly labeled, dated and covered. C. Ensure menu substitutions were documented. D. Ensure expired foods were discarded. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure within 14 days after the facility determined, or should have determined, that there was a significant change in the resident's physical or mental condition for 1 of 16 residents (Residents #5) reviewed for comprehensive assessments. The facility failed to complete a significant change MDS for Resident #5 within 14 days of 12/30/2024-the date she elected to receive hospice care. This failure could place residents at risk of not receiving coordinated and appropriate care between the nursing facility and hospice provider. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 4 staff observed for infection control. -CNA A did not perform hand hygiene properly while performing catheter care for Resident #7. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 of 5 residents (Resident #1) reviewed for transfer/discharge. The facility did not allow Resident #1 to return to the facility after evaluation and treatment at a Psych Hospital due to the resident potentially still having aggressive and physical behaviors towards others. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had a right to personal privacy which and confidentiality of his or her personal and medical records, which included included accommodations, medical treatment, written and telephone communication, personal care, visits, meetings of family, resident groups, for 1 (Resident #1) of 2 residents reviewed for resident privacy. The facility failed to keep Resident #1's catheter bag covered in a privacy bag. This failure could place residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (Resident #1 and Resident #2) residents reviewed for infection control. -Facility did not ensure that Resident #1's foley catheter bag remained off of the floor. -Facility did not ensure that Resident #2's foley catheter bag remained off of the floor. These deficient practices could place residents at risk of exposing them to care that could lead tot he spread of infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to label and date food properly. The facility failed to store frozen food properly. The facility failed to remove a dented can of mandarin oranges from circulation. These failures could place residents at risk of contracting foodborne illness. Findings Included: An observation on 10/15/24 at 09:47 AM of the upright freezer revealed the following: 1 resealable bag of what appeared to be breaded meat patties. No label no date. 1 box of green peas with blue plastic bag open leaving peas visible and open to air 1 box of mixed vegetables, blue plastic bag open leaving vegetables open to air An observation on 10/15/24 at 09:51 AM of the refrigerator revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect 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 for 2 (Resident #7 and Resident #20) of 12 residents and 3 of 6 anonymous residents reviewed for resident rights. 1. The facility failed to ensure Resident #7 and Resident #20 had a toilet that flushed properly. 2. The facility failed to ensure 3 of 6 anonymous residents had ready access to hot water in their rooms and/or in the shower. These failures could result in residents feeling frustrated and undignified in their living environment. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the right of the resident to make choices about aspects of his or her life in the facility that are significant to the resident for 1 (Resident #22) of 13 residents reviewed for resident rights. The facility failed to ensure Resident #22 was allowed to shower in the mornings as was her preference. This failure could put residents at risk of feeling devalued and uncomfortable in their home. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 1 of 5 residents (Resident #1) residing in the locked unit reviewed for accidents and hazards. The facility failed to ensure that an empty resident room that was under construction was safe and secured from residents in the locked unit. Resident #1 was able to enter the unlocked room and eloped through a hole in the wall. The opening in the wall was covered by plywood due to a missing air conditioning unit. Resident #1 removed the plywood and crawled through the opening. This failure, identified as past noncompliance, could affect residents in the locked unit of the facility by placing them at risk of serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received services in the facility with reasonable accommodation of resident needs and preferences for 2 of 12 (Resident #1 and Resident #7) reviewed for accommodation of needs. The facility failed to ensure that Resident #1's and Resident #7's call lights were within reach. This failure could affect residents who are dependent on staff for transferring in and out of bed and/or wheelchair, toileting, and activities of daily living, resulting in a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #10) of 12 residents reviewed for advanced directives. Resident #10 had a DNR is her record that had information for only one physician in section F. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on observations , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 2 (Resident #3, #7) of 15 residents reviewed for care plans. Residents #3 and #7 did not have interventions of a fall mat implemented that was listed in care plans. Resident #7's care plan was not revised after intervention of fall mat was discontinued. This failure can result in residents not receiving appropriate needs based on interventions listed in resident's care plans. Findings Included: Resident #3 Record review of Resident #3's face sheet on 9/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE] and a re-entry on 6/13/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens observed. DM failed to follow policy on hand hygiene prior to preparing trays for lunch by not practicing hand hygiene prior to serving food after leaving the kitchen area and touching surfaces. This failure can result in a risk of infection and cross contamination to residents of the facility.