Wellington Rehabilitation and Healthcare

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the resident received adequate supervision and assistance with devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on 1/10/2026, Resident #1 eloped was found in the alley behind the facility, attempting to get to the end of the alley where a coffee shop was located. This failure could result in serious injuries to residents and potentially death. The noncompliance was identified as PNC. This failure resulted in an identification of an (IJ) Immediate Jeopardy on January 10th, 2026, at 11:06 am. The IJ template was provided to the ADM and DON on February 17th, 2026, at 05:05 pm. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 3 residents reviewed for PASARR services. The facility failed to submit an NFSS request within 20 business days of Resident #1's IDT meeting held on 04/23/25. This failure could place residents at risk of not receiving the required care and services to attain and maintain their highest, practicable, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred safely, with a gait belt, correct positioning and with at least two staff, by CNA B when Resident #1 fell and sustained a femur (thigh bone) fracture which required surgery on 06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/13/2025. While the IJ was removed on 06/15/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the of the corrective systems . This failure could place residents at risk of unsafe transfers, falls, injuries, hospitalizations and/or death.

Inspectors wroteBased on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 of 4 (Resident #1) related to safe transfers. The facility failed to ensure CNA B used the accurate technique to transfer Resident #1 safely (with gait belt, correct positioning and/or two-people) on 06/10/2025. An Immediate Jeopardy (IJ) situation was identified on 06/23/2025. While the IJ was removed on 06/24/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of avoidable falls, injuries, hospitalization and/or death.

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of four residents (Resident #1) reviewed for abuse and neglect. The facility failed to thoroughly investigate a fall in which Resident #1 sustained a femur (thigh bone) fracture on 06/10/2025 during a transfer by CNA B. This failure could place residents at risk of further abuse, physical harm, mental anguish and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #36) reviewed for PASARR Level 1 screenings. The facility failed to notify the local authority of the PASARR I screen for Residents #36. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 09/27/2024. The non-compliance was identified as PNC. The facility had corrected the non-compliance on 9/27/2024 before the investigation/complaint began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of four residents reviewed for indwelling urinary catheters, in that: The facility failed to implement a batch order for daily catheter care when Resident #1 was admitted on [DATE] and failed to provide daily catheter care for Resident #1 from 7/2/2024 until 7/10/2024. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by facility staff for one (Resident #2) of ten residents reviewed for abuse, in that: The facility failed to protect Resident #2 from physical abuse by LVN A on 6/3/2024 when LVN A pulled on Resident #2's wheelchair causing him to fall to the ground. This failure placed residents at risk of not being protected from abuse, neglect, or exploitation.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights, in that: The facility failed to ensure Resident #1's NP was notified until the 5th day of her experiencing constipation. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Resident #14, Resident #34, and Resident #153 ) reviewed for accommodation of needs. The facility failed to ensure resident call lights were placed within their reach. This failure could place residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed ensure residents had the right to a safe, clean, comfortable, and homelike environment, in that: 1. The facility failed to ensure resident room floors in halls 200 and 300 didn't have a buildup of stains and physical dirt, scratches, peeling and chipping paint on the walls. 2. The facility failed to ensure the furniture wood was not chipping. 3. The facility failed to ensure there was not a strong urine odor in the facility upon entrance to the building. 4. The facility failed to ensure there were no dirty clothes on the floors of residents closets. 5. The facility failed to ensure the community showers on the halls didn't have soap scum. 6. The facility failed to ensure the toilets were not leaking in the residents rooms. These failures could place residents at risk of a diminished quality of life.

Inspectors wroteBased on observation , interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 3 residents (Residents #7, #40 and #104) reviewed for ADL care. The facility failed to ensure Residents #7, #40 and #104 received their bath/showers three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection, and loss of self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure a drug regimen review for each resident was reviewed at least once a month by a licensed pharmacist for five of five reviewed for drug regimen review. The facility failed to document an MRR for Residents# 1, 15, 8, 34 and 22 for the months of January, February and March 2024. This failure could place residents at risk of adverse drug consequences and a decline in their physical and mental health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 2 medication carts (Medication Cart #1) reviewed for medication storage . The facility failed to ensure Medication Cart # 1 was not left unattended and unlocked. This failure could place residents at risk of obtaining access to prescription and over-the-counter medication, that could cause overdose, allergic reactions, poisoning or exacerbation of illness and symptoms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #8) reviewed for physician orders. The facility failed to obtain a physician's order prior to providing treatment for an open wound to the right lower forearm for Resident #8. This deficient practice could place residents at-risk of inadequate monitoring and treatment of medical conditions and an infection of the skin wound.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 5 residents (Residents #8) reviewed for respiratory care. The facility failed to ensure Resident #8's oxygen concentrator had a clean filter in place, humidifier was filled and dated, and tubing was changed as ordered by physician. This failure could place residents at risk for respiratory infections .

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for three of six residents (Residents #1, #2 and #3) reviewed for quality of life. The facility failed to answer Resident #1, Resident #2 and Resident #3 call lights in a timely manner. The failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues.

Inspectors wroteBased on interview and record review the facility failed to ensure a comprehensive assessment was completed within 14 calendar days after admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition, for one of one resident record reviewed for comprehensive assessments. Resident #1 did not have a completed admission/comprehensive MDS assessment within 14 days following his admission to the facility. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 3 of 10 residents (Residents #12, #17, and #35) reviewed for homelike environment. 1. The facility failed to ensure Resident #12's room and bathroom was not in a state of disrepair. 2. The facility failed to ensure Resident #17's room and bathroom were clean and not in a state of disrepair. 3. The facility failed to ensure Resident #35's room was clean and free of debris under his bed. 4. The facility failed to ensure the intake vent on the floor next to Hall 300 nurses' station was clean of dirt and debris. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 10 residents (Resident #109, Resident #12, Resident #14, and Resident #24) reviewed for ADL's. The facility failed to ensure Resident #109, Resident #12, Resident #14 and Resident #24 fingernails were trimmed and clean. This failure could place residents at risk of scratches, infections, and poor self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging independence and interaction in the community for 3 of 4 residents (Residents #14, #24 and #160) reviewed for activities. The facility failed to consistently provide activities for Resident #14, Resident #24 and Resident #160. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were maintaining acceptable parameters of nutritional status for 13 (Resident #1, #2, #3, #4, #9, #15, #16, #18, #24, #29, #32, #42 and #44) residents out of 30 residents reviewed for accurate weights. The facility failed to establish a consistent method of weighing residents to ensure accuracy of resident weights. These failures put residents at risk for undetectable weight loss, malnutrition, and poor quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident # 14, Resident # 24, and Resident # 42 reviewed for infection control. The facility failed to follow the infection control protocol. This failure could place residents at risk of transmission of infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one of five residents (Resident #7) reviewed for resident rights. The facility failed to ensure Resident #7 was fed by a staff member sitting at eye level rather than standing over her. This failure could place residents at risk for a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 10 residents (Resident #4) reviewed for self-determination. The facility failed to ensure Resident #4 was allowed to choose the type of liquids he preferred when he expressed he would not drink nectar thick liquids. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality or care and failed to ensure a care plan was developed within 48 hours of a resident's admission for 2 of 3 residents (Resident #159 and Resident #160) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #159 and Resident #160 within the required 48-hour timeframe. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for two of six residents (Resident #111 and #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #111's oxygen tubing was dated. 2. The facility failed to ensure Resident #14's oxygen concentrator had a humidifier bottle per physician orders. These failures could place residents at risk for discomfort and respiratory infections.