Wellington Health and Rehab: Fall Prevention Failures - KS
The resident, identified in inspection records as R28, had already fallen after his catheter collection bag and tubing caught him during a transfer. He had dementia and often forgot to use his call light before heading to the bathroom on his own.
After the fall on August 21, staff held a care plan conference and settled on a solution: switch R28 to a leg bag, which would keep the urine collection bag strapped to his leg rather than hanging loose where it could snag him. The intervention was added to his Treatment Administration Record on August 22. Staff began signing off that the leg bag was in use.
It was not in use.
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, weeks before the care plan conference that was supposed to make it mandatory. Asked about the gap between what staff signed and what actually happened, Administrative Nurse E said the resident had refused the leg bag, but that refusal had never been documented anywhere.
The fall on August 21 also lacked a thorough investigation, Administrative Nurse E confirmed.
CNA M had described R28 as cooperative, someone who knew when he needed the bathroom and would turn on his call light so staff could walk with him. But Administrative Nurse F told inspectors that his dementia meant he often forgot to do exactly that.
A resident who forgets to call for help, a catheter bag loose enough to knock him down, a documented intervention that staff recorded as completed and wasn't, and a fall that went uninvestigated. By the time inspectors arrived on August 26, R28's care plan still listed the leg bag. He still did not have one.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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, had already fallen after his catheter collection bag and tubing caught him during a transfer.
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.