Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luxe At Wellington Rehabilitation Center The during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders and provide timely care in several cases: a resident did not receive ordered IV antibiotics for multiple days after an ID consultant extended therapy; another resident’s left leg skin tear lacked ongoing assessment and physician-ordered wound care, with the same dated dressing left in place for days; and two residents on Metoprolol had missing or inaccurate BP/HR documentation and repeated administration of the drug despite ordered hold parameters for low blood pressure or heart rate.
A resident with a history of stroke and hemiparesis did not receive Lactulose as prescribed due to an LPN administering an incorrect dose from a bottle labeled for another resident and failing to reorder the medication in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant decline, including unresponsiveness, refusal of medications, and not eating. Staff did not promptly recognize or escalate the change in condition, resulting in delayed assessment and transfer to the hospital, where the resident was diagnosed with a CVA and admitted to the ICU.
A resident admitted for post-acute care with a diagnosis of atrial fibrillation did not receive the prescribed anticoagulant Eliquis, despite multiple provider notes and hospital records indicating its necessity. The medication was neither ordered nor administered during the resident's stay, and this oversight was not identified by the clinical team or pharmacist. The resident was later hospitalized with bilateral pulmonary embolism, revealing the failure to provide care according to professional standards.
Surveyors identified that multiple residents and their families experienced significant barriers to communication and a lack of staff presence, including difficulty reaching staff by phone, infrequent staff visits to resident rooms, and inability to contact social services. These issues affected residents with both mild cognitive impairment and intact cognition, and were observed during routine facility operations.
A resident admitted after back surgery with an indwelling urinary catheter did not receive appropriate care to assess or remove the catheter. The facility's records lacked documentation of any attempt to conduct a voiding trial or a urinary consult, despite the resident's cognitive ability and communication that the catheter was meant to be removed shortly after admission. The catheter remained in place until a follow-up appointment, highlighting a lapse in the facility's process.
A facility failed to change a resident's midline IV dressing as ordered, leading to a deficiency. The resident had a midline catheter placed with orders for dressing changes every Tuesday and as needed. However, the dressing was only changed on specific dates, and an observation revealed a loose dressing with a label from the technician who inserted the line. The Unit Manager confirmed the oversight, acknowledging that nurses should have noticed the need for a new dressing.
The facility staff failed to adequately monitor and document the care of two residents who experienced significant changes in condition, leading to hospitalization. One resident with chronic hematuria was found unresponsive with profuse bleeding, while another resident exhibited confusion and lethargy without proper follow-up on ordered tests. Additionally, a third resident's skin condition was not properly assessed or documented, indicating deficiencies in the facility's care processes.
A facility failed to properly secure a urinary catheter for a resident, leading to potential complications. During care, the catheter was not anchored, causing discomfort due to pulling. The catheter's securement device was not attached, and a blue clamp was not used. Despite intervention to minimize pulling, the catheter remained unsecured, contrary to the resident's care plan for catheter management.
The facility failed to ensure nurses demonstrated competency in medication administration, affecting two residents. One resident received medications without required blood pressure monitoring, while another was given medication despite low blood pressure readings, contrary to physician's orders. The DON confirmed these lapses.
The facility experienced staffing deficiencies, leading to delayed medication administration for a resident with Parkinson's and communication barriers for Spanish-speaking residents. Family members reported long response times to call lights and unmet basic needs, particularly during weekends and at night.
Three residents reported being treated without dignity and respect in the facility. A resident experienced pain during care and felt ignored by staff, while another faced abrupt behavior from a CNA and was left in a soiled diaper. A third resident felt disrespected by staff who rolled their eyes when she asked for help. The facility's administration acknowledged the lack of dignified treatment.
The facility failed to provide adequate communication for two residents who preferred Spanish, leading to a deficiency in care. One resident, with cognitive impairment, had no Spanish-speaking staff available, and no translation methods were used. Another resident, cognitively intact, was not offered a language line, despite limited Spanish-speaking staff. Family concerns about communication were noted.
A resident with Parkinson's Disease experienced delays in receiving prescribed medications, affecting her therapy participation due to dizziness. The facility's Medication Administration Record showed multiple instances of late administration, which was confirmed by the DON as not adhering to the prescribed time frames.
The facility failed to deliver meals on time and provide beverages of choice for three residents, leading to dissatisfaction. A cognitively intact resident reported consistently late breakfasts and lack of coffee. Another resident also experienced late meals and absence of coffee. A recently admitted resident received meals late and was not provided with preferred whole milk, despite it being documented. Staff interviews revealed a lack of awareness about these issues.
A resident's representative experienced a significant delay in receiving a refund for services not rendered after the resident's death. Despite multiple attempts to contact the facility, the refund was not processed until 188 days later, due to inaction by the new BOM and Administrator.
The facility failed to document and address grievances from two residents and their representatives, violating their rights to voice grievances without reprisal. One resident's representative sought a refund for services not rendered, while another reported dissatisfaction with care, but neither complaint was documented in the grievance log.
The facility failed to thoroughly investigate falls with major injuries for two residents. One resident with cognitive impairment and a history of falls was found with a hip fracture, and the investigation lacked documentation from all nursing staff. Another resident, cognitively intact and with a history of hip surgery, was found with a skin tear and later diagnosed with a hip fracture, but no thorough investigation was conducted. The Administrator acknowledged the deficiencies in both cases.
Failure to Follow Physician Orders for Antibiotics, Wound Care, and Antihypertensives
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and residents’ needs. One cognitively intact resident on IV Daptomycin for a MRSA left hip wound had an infectious disease (ID) consultant visit, after which the ID physician ordered continuation of IV Daptomycin until a specified date. The resident reported taking a photo of the written order and giving it to the nurse upon return from the appointment. Despite this, the facility’s records show no administration of the antibiotic or documented reason for non‑administration over three consecutive days, and the Unit Manager later stated she was unaware of any issue and had no explanation for why the consultant’s order was not implemented. Another resident was admitted without documented left leg skin issues, but a weekly skin assessment later documented a skin tear to the left lower leg following a fall. Subsequent weekly skin checks did not mention the skin tear, and there were no physician orders for care of the left leg wound. Over several days of observation, the same large wound dressing, dated from the day of the fall, remained on the resident’s left leg, with curled edges and a visible bloody area beneath, indicating the dressing had not been changed. The Unit Manager, when shown the dressing, agreed with the findings. The facility also failed to follow and document parameters for antihypertensive medications for two residents with hypertension. One resident had an order for Metoprolol with instructions to hold the dose for systolic blood pressure less than 100 or heart rate less than 60, yet the MAR for the month lacked any blood pressure or heart rate readings associated with the medication doses. During a medication pass, the RN held a dose based on a low blood pressure reading, but the MAR reflected a different blood pressure not taken at that time, and routine vital sign documentation did not specify times or consistently capture readings at both ordered dosing times. For another resident with multiple chronic conditions, including chronic diastolic heart failure and hypertension, Metoprolol was ordered with parameters to hold for low systolic or diastolic blood pressure or low heart rate. Review of the MAR showed multiple instances where the medication was documented as given despite diastolic blood pressures below the ordered threshold, and both the DON and an LPN later acknowledged that the medication had been administered when it should have been held.
Failure to Administer Medication as Prescribed and Ensure Timely Refills
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and hemiparesis did not receive medication as prescribed and experienced a delay in medication refills. During a medication administration observation, an LPN prepared and administered several medications, including Lactulose, but used a bottle labeled for a different resident. The LPN stated that the resident was out of their prescribed Lactulose and that it had to be reordered. The medication was last reordered over a month prior, and the LPN admitted to only reordering it on the day of the observation. Further review revealed that the LPN administered 30ml of Lactulose, despite the physician's order specifying 15ml twice daily. The LPN initially believed the order was for 30ml, but upon checking the electronic record, confirmed the correct dose was 15ml. This resulted in the resident receiving an incorrect dose and medication from a bottle not labeled for them, as well as a lapse in timely medication refills.
Failure to Timely Respond to Resident's Change in Condition Resulting in Hospitalization
Penalty
Summary
Facility staff failed to protect a resident from neglect by not responding in a timely manner to a significant change in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including dysarthria following cerebral infarction, heart failure, and atrial fibrillation, was admitted for post-acute care. On the morning following admission, documentation indicated the resident was alert and responsive, but by the next day, staff observed that the resident was not opening her eyes, was not eating, and was refusing medications. Despite these changes, there was a lack of prompt and thorough assessment and escalation by nursing staff. Throughout the morning and early afternoon, the resident remained unresponsive to verbal stimuli, did not eat breakfast or lunch, and did not take her scheduled medications. The primary CNA reported these changes to the nurse, but the nurse assumed the resident was tired and did not immediately escalate the situation. The PA was not notified of the resident's condition until the afternoon, and the unit manager was unaware of the resident's status until late in the day. When the resident was finally assessed by multiple nurses, she was found to be nonverbal, with abnormal pupil response and froth in her mouth, prompting an emergency transfer to the hospital. Upon arrival at the hospital, the resident was admitted to the ICU with a diagnosis of cerebrovascular accident (CVA) and had a Glasgow Coma Scale score of 8, indicating a coma. The facility's failure to recognize and respond to the resident's change in condition in a timely manner resulted in a delay in necessary medical intervention and transfer to a higher level of care.
Failure to Administer Prescribed Anticoagulant for Resident with Atrial Fibrillation
Penalty
Summary
A deficiency occurred when a resident admitted for post-acute care with a diagnosis of atrial fibrillation (Afib) did not receive the prescribed anticoagulant medication, Eliquis, as indicated in her hospital discharge records and multiple provider notes. Despite documentation from the hospital and repeated references in progress notes by nurse practitioners, physician assistants, and physicians that the resident was to be on Eliquis for Afib and deep vein thrombosis (DVT) prophylaxis, there was no corresponding physician order or administration of Eliquis during the resident's stay at the facility. The March Medication Administration Record (MAR) confirmed that Eliquis was never given, and the medication was not listed in the facility's physician orders. The resident's care plan acknowledged her altered cardiovascular status, including Afib, hypertension, and hyperlipidemia. Hospital records prior to admission to the facility indicated that Eliquis was to be restarted after stopping heparin, and the resident was cleared for discharge with instructions for follow-up related to paroxysmal atrial fibrillation. Despite this, the facility failed to ensure the continuation of Eliquis therapy, and the oversight was not identified by the pharmacist during a medication regimen review or by the clinical team, who continued to document that the resident was on Eliquis based on previous notes rather than verifying actual orders and administration. The deficiency became evident when the resident experienced a syncopal episode with hypoxia during occupational therapy, leading to her transfer to the hospital. Hospital records from this subsequent admission revealed a diagnosis of bilateral pulmonary embolism, for which a mechanical thrombectomy was performed. Interviews with facility staff confirmed that the absence of Eliquis was not recognized, and documentation errors perpetuated the assumption that the resident was receiving the medication.
Failure to Ensure Resident Dignity and Communication
Penalty
Summary
Surveyors found that the facility failed to honor residents' rights to a dignified existence and effective communication for three of four sampled residents. During a 45-minute observation on the second floor, no staff members were present at the nurses' station or visible on the unit, which housed 40 residents. Interviews revealed that one resident's spouse was unable to contact facility staff by phone and rarely saw nurses or CNAs during visits. Another resident's spouse reported minimal staff presence in the resident's room, difficulty obtaining assistance, and a lack of follow-up from the front desk. Additionally, a resident expressed frustration at being unable to reach social services by phone, despite repeated attempts and being transferred by the front desk without success. Record reviews indicated that the affected residents included individuals with mild cognitive impairment following a cerebrovascular accident, as well as residents with intact cognition, one of whom was admitted for aftercare following joint replacement surgery. The administrator acknowledged receiving frequent messages from residents and families and noted that the social worker was off on the day in question, but these explanations did not address the observed lack of staff presence and communication barriers experienced by residents and their representatives.
Failure to Assess and Remove Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident was admitted to the facility following back surgery, during which a Foley catheter was placed. The hospital discharge instructions did not include any information regarding the catheter, and there was no documentation of an attempt to remove it. Upon admission to the facility, the resident's records indicated the presence of the catheter but lacked any assessment or rationale for its continued use. The facility's records did not document any attempt to conduct a voiding trial or a urinary consult, which are standard procedures to determine if the catheter is still necessary. The resident, who was cognitively intact, expressed to the facility staff and doctors that the catheter was intended to be removed shortly after admission. However, the facility did not act on this information, and the catheter remained in place until the resident's follow-up appointment, where it was noted that the catheter should have been removed two to three days post-admission. The First Floor Unit Manager confirmed that there was no documentation in the electronic record regarding an assessment or attempt to remove the catheter, indicating a lapse in the facility's process to ensure catheters are not retained longer than necessary.
Failure to Change IV Dressing as Ordered
Penalty
Summary
The facility failed to ensure proper care and services for the intravenous line of a resident, as evidenced by the lack of dressing changes as per physician orders. The resident, who was admitted to the facility with several peripheral IVs, had a midline catheter placed on October 28, 2024, with orders to change the dressing every Tuesday and as needed using sterile technique. However, the Medication Administration Record (MAR) showed that the dressing was only changed on October 29, November 5, and November 12, 2024, which did not align with the required schedule. During an observation on November 13, 2024, the midline IV access was noted to have a loose dressing with a label that had a nurse's initials not matching any current facility nurse, indicating it was from the technician who inserted the line. The First Floor Unit Manager confirmed the findings and acknowledged that the nurses, who were flushing the line twice daily, should have noticed the need for a new dressing. This oversight led to the deficiency in providing safe and appropriate administration of IV fluids for the resident.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility staff failed to provide necessary care and services for two residents who experienced significant changes in condition requiring hospitalization. One resident, who had chronic hematuria and was on anticoagulant medication, was found unresponsive with profuse bleeding from the urinary catheter site. Despite initial interventions, such as starting intravenous fluids, the resident's condition deteriorated, leading to a transfer to the emergency room where the resident was pronounced dead. The staff did not adequately monitor or document the resident's condition, including vital signs and the amount of blood loss, after the change in condition was identified. Another resident, admitted for rehabilitation after knee replacement, exhibited changes in condition, including lethargy and confusion. Despite orders for STAT labs and imaging, there was no evidence that these were completed or that the resident was adequately monitored. The resident's condition worsened, leading to a transfer to the hospital where a critical white blood cell count was noted, indicating a severe infection. The staff failed to document reassessments or follow-up on the ordered diagnostic tests, contributing to the delay in appropriate care. Additionally, the facility staff failed to assess and document the resolution of a skin condition for a third resident. The resident was treated with zinc oxide ointment for redness on the buttocks, but there was no documentation of a skin assessment to determine if the condition met criteria for a pressure wound or if it had resolved after treatment. This lack of documentation and assessment highlights a deficiency in the facility's monitoring and care processes.
Failure to Secure Urinary Catheter Properly
Penalty
Summary
The facility failed to implement proper care practices to prevent excessive tension on an indwelling urinary catheter for a resident, leading to potential complications. During an observation of catheter and wound care, it was noted that the resident's catheter was not properly secured, which resulted in pulling and discomfort for the resident. The catheter was observed to have a wrinkled securement device that was not attached to the resident's skin, and a blue clamp was not in use. As the resident was turned during care, the catheter tubing pulled, causing the resident to moan in discomfort. The Unit Manager intervened by placing the catheter bag on the bed to minimize pulling, but the catheter was still not secured with a new device or the blue clamp. The resident, who was assessed as severely impaired for daily decision-making skills and had an indwelling urinary catheter due to obstructive uropathy, was at risk for injury or infection. The care plan for the resident included checking catheter tubing for patency and positioning the catheter bag to promote dignity and drainage, but these interventions were not adequately followed during the observed care.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in medication administration and adherence to physician's orders, affecting two residents. Resident #3, admitted for rehabilitation with diagnoses including heart failure and hypertension, had physician's orders for Amlodipine Besylate and Carvedilol with specific parameters to hold the medication if the systolic blood pressure was less than 110 or heart rate was less than 60. However, the Medication Administration Record for October 2024 showed that the resident received these medications on multiple days without evidence of blood pressure monitoring, indicating a failure to follow the prescribed parameters. Similarly, Resident #2, also admitted for rehabilitation with heart failure and hypertension, had orders for Methocarbamol with instructions to hold the medication if the systolic blood pressure was less than 105 or if the resident was lethargic. Despite these parameters, the resident received the medication on two occasions with blood pressure readings below the threshold. An interview with the Director of Nursing and the Chief Nursing Officer confirmed that the staff did not document the vital signs for Resident #3 and administered medication to Resident #2 despite the prescribed parameters.
Staffing Deficiencies and Communication Barriers in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing, resulting in delayed medication administration for a resident with Parkinson's disease. The resident's family member reported that the resident's participation in therapy declined due to not receiving medications on time, affecting her blood pressure and causing dizziness. A review of the medication administration record revealed multiple instances where the resident's Parkinson's medications were administered late, sometimes by several hours, which was confirmed by the Director of Nursing. Additionally, there were communication issues for residents who only spoke Spanish, as there were no staff available who could communicate with them. Family members expressed concerns about the lack of Spanish-speaking personnel, despite being informed otherwise during the care plan meeting. This communication barrier, coupled with long response times to call lights, contributed to the perception of insufficient staffing, particularly at night. Numerous residents and family members voiced complaints about the facility's staffing levels, citing long wait times for assistance, unmet requests for basic needs, and inadequate supervision. Residents reported waiting for hours to have their call lights answered and to receive personal care, such as changing soiled briefs. These issues were more pronounced during weekends, with some residents experiencing distressing situations due to the lack of timely staff intervention.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by interviews and record reviews. Resident #18, who was cognitively intact, reported that some staff members seemed indifferent to her needs. She experienced pain during care and felt that her concerns were not being addressed, as staff did not conduct regular rounds to check on her well-being. Additionally, she felt disrespected by a therapist who interrupted her meals to conduct exercises, disregarding her preferences. Resident #39, also cognitively intact, described an incident where a CNA was abrupt and disrespectful while assisting her with toileting. She also reported being left in a soiled diaper for over an hour and having to scream for assistance because the call light was out of reach. Resident #33 expressed that some staff members were disrespectful, rolling their eyes when she asked for help, which made her feel upset. The facility's administrator and social service assistant acknowledged that Resident #33 was not treated in a dignified manner.
Deficiency in Communication with Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure adequate communication for two residents who were unable to speak English, leading to a deficiency in their care. Resident #29, who was admitted with diagnoses including Major Depressive Disorder and Difficulty in Walking, was documented as having a cognitive impairment and a preference for communication in Spanish. Despite this, there were no Spanish-speaking staff available to communicate with her, and no alternative communication methods, such as translation apps, were utilized by the care staff. This lack of communication left Resident #29 unable to express her needs or understand the staff. Similarly, Resident #394, who was cognitively intact and preferred to communicate in Spanish, was observed interacting with staff in English. The resident reported not being offered any communication system, such as a language line, to facilitate understanding. The family member of Resident #394 expressed concerns about the lack of Spanish-speaking personnel, despite being informed otherwise prior to admission. Interviews with facility staff revealed that there were limited Spanish-speaking nurses and CNAs available, and while a language line was supposed to be used when no Spanish-speaking staff were available, it was not being utilized effectively.
Failure to Administer Medications Timely for a Resident with Parkinson's
Penalty
Summary
The facility failed to ensure the timely administration of prescribed medications for a resident diagnosed with Parkinson's Disease, Syncope and Collapse, Orthostatic Hypotension, and Hypertension. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported running out of medications for 1-2 days on multiple occasions. This issue was corroborated by the resident's family member, who noted a decline in the resident's participation in therapy due to dizziness caused by the untimely administration of medications. A review of the Medication Administration Record revealed multiple instances where the resident's Parkinson's medications, Carbidopa-Levodopa Oral Tablet and Carbidopa-Levodopa ER Oral Tablet Extended Release, were administered late, sometimes by more than two hours. The Director of Nursing confirmed that medications should be given within one hour before or after the prescribed time, as per physician orders, but acknowledged that this was not consistently followed for the resident in question.
Failure to Provide Timely Meals and Beverages of Choice
Penalty
Summary
The facility failed to ensure timely meal delivery and provide beverages of choice for three residents, leading to dissatisfaction and unmet preferences. Resident #18, who was cognitively intact, reported consistently receiving breakfast late, between 9 AM and 10:30 AM, and noted the absence of coffee on certain days. Observations confirmed the late delivery of breakfast trays, with one instance of breakfast being served at 9:40 AM and another at 10:30 AM. Resident #31 also reported late breakfast delivery and a lack of coffee for two days, which was usually provided with meals. Both residents expressed frustration over the delays and lack of preferred beverages. Resident #143, recently admitted and alert, also experienced late meal deliveries and a lack of coffee for two days. The resident expressed dissatisfaction with breakfast being served as late as 11:30 AM, lunch at 3 PM, and dinner at 7:30 PM. Additionally, Resident #143 preferred whole milk, which was documented on the meal ticket, but was repeatedly provided with nonfat milk instead. Despite the meal ticket clearly indicating the preference for whole milk, the facility failed to meet this dietary request. Interviews with the Unit Manager and Regional Food Service Manager revealed a lack of awareness regarding these issues, indicating a breakdown in communication and adherence to resident preferences.
Delayed Refund Issuance After Resident's Death
Penalty
Summary
The facility failed to issue a refund to the representative of a resident within 30 days of the resident's death. The resident was admitted for skilled rehabilitation services but was discharged to a hospital due to respiratory distress and subsequently passed away. The representative, who had power of attorney, paid $2,550 for continued skilled services, which were not rendered due to the resident's hospital transfer and death. Despite multiple attempts by the representative to contact the facility for a refund, including phone calls and in-person visits, the facility did not process the refund in a timely manner. The Business Office Manager (BOM) and Administrator, both new to their positions, failed to follow up on the refund request. The BOM did not document the refund claim in the resident's financial record and did not pursue the matter after contacting the Regional Office. The Administrator, who was initially serving as Interim Administrator, forwarded the representative's voicemail to the business office but did not ensure the issue was resolved. The Grievance Officer was unaware of the refund request, and no grievance was filed. The refund was eventually processed 188 days after the resident's death, following the surveyor's intervention.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and act upon grievances reported by two residents and their representatives in a timely manner, violating the residents' rights to voice grievances without discrimination or reprisal. The facility's grievance policy required all grievances to be considered and responded to, but this was not adhered to in the cases of the two residents involved. In the first case, a resident's representative, who held power of attorney, paid for continued skilled rehabilitation services after the resident's skilled services ended. However, the resident was discharged to a hospital the same night and subsequently passed away. The representative sought a refund for the services not rendered, but despite multiple attempts to contact the facility, including speaking with the Business Office Manager (BOM) and the Administrator, no refund was issued, and the grievance was not documented in the facility's grievance log. In the second case, another resident's representative reported dissatisfaction with the care provided, including the resident being left in a wheelchair for hours and not receiving timely assistance with turning off lights or addressing medical concerns. Despite these complaints, there was no documentation of the grievances in the facility's log. The facility only became aware of these issues during a follow-up call after the resident was discharged, but the grievances were still not recorded in the log.
Failure to Investigate Falls with Major Injuries
Penalty
Summary
The facility failed to thoroughly investigate falls with major injuries for two residents. Resident #2, who had multiple diagnoses including a history of falls and cognitive impairment, was found on the floor next to her bed with a hip fracture. The facility's investigation report lacked documentation from all nursing staff scheduled to care for Resident #2 on the day of the fall, and the Administrator admitted that the investigation was not properly conducted and did not verify if the care plan was followed prior to the fall. Resident #6, who was cognitively intact and had a history of hip surgery, was found on the floor in a sitting position with a skin tear and later diagnosed with a right hip fracture. The incident report for Resident #6 did not include statements from the nursing staff caring for her on the day of the incident, and no thorough investigation was conducted. The Administrator acknowledged that an investigation should have been done, especially considering Resident #6's medications that increased her fall risk. Both cases highlight the facility's failure to conduct comprehensive investigations into falls with major injuries, as required by their protocols. The lack of thorough documentation and investigation into these incidents indicates a significant deficiency in the facility's handling of fall-related events, potentially compromising resident safety and care quality.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 158 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wellington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Palm Beach Health And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Aviata At Greenacres | 4.1 mi | ★★★★★ | 5 | 0 |
| Aviata At Coral Bay | 5.4 mi | ★★★★★ | 0 | 0 |
| Pine Trail Nursing And Rehab Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Aviata At West Palm Beach | 6.1 mi | ★★★★★ | 18 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.