Wellington Health And Rehab

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

supposed to have a catheter leg collection bag on during the day because he maneuvers his own catheter bag and tubing, and he gets tangled in it.

On 08/25/25 at 11:54 AM, CNA M stated Resident R28 was able to transfer himself with staff assistance when he gets shaky. She reported Resident R28 knew when he needed to have a bowel movement and would turn on his call light for staff to walk with him to the bathroom. CNA M stated the resident was at risk for falls when he gets shaky, but he was good about letting the staff know when he needed to walk, and the staff assisted him to prevent him from falling.

On 08/26/25 at 12:36 PM, Administrative Nurse E confirmed Resident R28 was supposed to have a leg bag for urine collection for his catheter because the resident had fallen related to getting tangled in the catheter tubing and collection bag when transferring himself and toileting. She confirmed the care plan conference dated 08/21/25 included the discussion of the resident’s fall and review of the existing interventions.

Administrative Nurse E said the use of a leg bag as a fall intervention was discussed and added to the Treatment Administration Record (TAR) on 08/22/25 to ensure staff would check for the leg bag placement.

On review of the resident’s TAR, she confirmed the staff had signed the leg bag as used from 08/22/25 to current date, but said the leg bag had not been used because the resident refused, though it was not documented. Additionally, she verified the resident’s fall on 08/21/25 lacked a thorough investigation, with an intervention initiated to prevent further falls.

On 08/26/25 at 12:56 PM, Administrative Nurse F confirmed on 08/21/25, staff identified concerns related to the resident’s multiple falls, and interventions were discussed during a care plan conference. She confirmed Resident R28 had a diagnosis of dementia and often forgot to use his call light when going to the bathroom. Administrative Nurse F verified Resident R28's Care Plan included to use a leg bag for the collection of urine from the catheter to prevent the resident from getting tangled in the straight drain urine collection bag and tubing when toileting himself.

On 08/26/25 at 01:10 PM, Administrative Nurse F verified the staff had signed Resident R28's TAR to indicate the resident had the leg bag in place, and he did not have a leg bag in place. She reported the direct care staff confirmed the leg bag had not been used as an intervention to prevent falls since 07/09/25.

The facility policy titled Fall and Fall Risk, Managing F-F689” dated 06/2025, documentation included, “ . based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellington Health and Rehab

1600 W 8th Street Wellington, KS 67152

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

arm, but said he had not reported his pain to the staff. He turned his call light on. On 08/25/25 at 11:54 AM, Certified Nurse Aide (CNA) M entered Resident R28's room and asked the resident if she could help him with anything. Resident R28 said no. Resident R28 did not report the presence of pain he had described six minutes earlier.On 08/25/25 at 11:59 AM, CNA M confirmed Resident R28 did not report pain and said the resident did not recall why he had turned his call light on. CNA M reported the resident often complained of back pain, and the pillow that was behind his back was put there by the staff because it seemed to help. CNA M stated that when a resident reported pain, the staff would try to make the resident comfortable and notify the nurse, who should assess the resident. She confirmed Resident R28 had dementia and sometimes forgot what he turned his light on for, but he would turn on his call light to let the staff know if he needed something. CNA M stated

she would notify the nurse he reported pain. On 08/25/25 at 07:17 PM, Resident R28's representative confirmed the facility was aware of the concerns related to Resident R28's pain. She stated Resident R28 would use his call light; however,

he may forget why he turned the call light on for assistance, and if the staff does not specifically ask if he is having pain, he will not remember to tell them. Resident R28's representative reported a meeting was held with the facility staff on 08/21/25, where they discussed the resident's increased pain. The staff agreed they would contact the physician to request acetaminophen on a scheduled basis rather than just upon request, since

he could not remember to express to the staff when he had pain. Resident R28's representative expressed concern that the pain would result in a decline in the resident's ability to ambulate and said he was using his wheelchair more often.On 08/26/25 at 12:36 PM, Administrative Nurse E confirmed that the care plan conference dated 08/21/25 included the discussion of the Resident R28's pain and the request of his representative for the facility to contact the physician and ask for scheduled acetaminophen to manage the resident's pain.

Additionally, upon review of Resident R28's physician orders, progress notes, and care plan, Administrative Nurse E confirmed nothing had been done to address Resident R28's pain in response to the concerns voiced by the resident's representative in the care plan conference on 8/21/25.On 08/26/25 at 12:56 PM, Administrative Nurse F confirmed the 08/21/25 care plan conference where staff identified concerns related to Resident R28's pain and the interventions that were discussed. She confirmed the resident had a diagnosis of dementia and often forgot to use his call light. The facility policy titled F-F697, Pain Assessment and Management, dated 04/2025, documentation included discussion with the resident (or legal representative) his or her goals for pain management, and satisfaction with the current level of pain control. Staff should assess and re-assess

the resident's pain and the consequences of pain upon admission, quarterly, and with new pain.

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Federal health inspectors cited WELLINGTON HEALTH AND REHAB in WELLINGTON, KS for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-26.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of WELLINGTON HEALTH AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited WELLINGTON HEALTH AND REHAB in WELLINGTON, KS for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-26.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of WELLINGTON HEALTH AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited WELLINGTON HEALTH AND REHAB in WELLINGTON, KS for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-26.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of WELLINGTON HEALTH AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.