Wellington Health and Rehab: Fall Prevention Failures - KS
The resident, identified in inspection records as R28, has a urinary catheter and a diagnosis of dementia. He moves himself around and manages his own transfers, but he gets shaky, and he sometimes forgets to use his call light before heading to the bathroom. The danger inspectors documented was specific: when R28 tries to toilet himself, he gets tangled in the long tubing and collection bag attached to a straight-drain catheter. He had already fallen because of it.
After a fall on August 21, nursing staff held a care plan conference that same day. They reviewed the existing interventions and identified the catheter tubing as a hazard. The solution they landed on was a leg bag, a smaller collection bag that straps to the thigh and keeps the tubing close to the body, out of the way when a resident is moving. The intervention was added to R28's Treatment Administration Record on August 22.
From that date forward, staff signed the TAR each day to indicate the leg bag was in place.
It was not in place. Administrative Nurse F confirmed to inspectors on August 26 that direct care staff had told her the leg bag had not been used as a fall intervention since July 9, more than six weeks before the inspection. Nobody had documented that R28 refused it, even though Administrative Nurse E acknowledged the refusal was the reason it wasn't being used.
That gap matters. R28 has dementia and, as Administrative Nurse F noted, often forgets to call for help before walking to the bathroom on his own. CNA M told inspectors R28 was good about using his call light when he needed to walk, but also confirmed he was at fall risk when he gets shaky and required staff to walk with him. The catheter tubing, left unmanaged, remained the same tripping hazard it had been when he fell.
What the TAR showed and what was actually happening in R28's room were two different things for weeks.
Administrative Nurse E confirmed the August 21 fall itself lacked a thorough investigation. The care plan conference happened, the intervention was identified, and the TAR entry was made, but the underlying fall was not fully examined. The leg bag was entered into the record as an active intervention, and staff kept signing it off as completed, and none of it was accurate.
The inspection was complaint-based and conducted August 26, 2025. Inspectors cited the facility under F689, the federal tag covering accidents and fall prevention, at a level of minimal harm or potential for actual harm, affecting a few residents.
CNA M described R28's situation with some care: he could transfer himself with assistance when he got shaky, he knew when he needed the bathroom, and staff walked with him to prevent falls. The picture she drew was of a resident who had some awareness of his own limits. But Administrative Nurse F's account complicated that. R28 has dementia. He often forgets to call. The very thing that made the leg bag necessary was the same thing that made consistent documentation and follow-through essential.
Staff signed the record. Nobody checked whether the record matched reality. And the resident who fell because he got tangled in his catheter tubing went on sleeping without the device that was supposed to prevent it from happening again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellington Health and Rehab from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
WELLINGTON HEALTH AND REHAB in WELLINGTON, KS was cited for violations during a health inspection on August 26, 2025.
The resident, identified in inspection records as R28, has a urinary catheter and a diagnosis of dementia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.