Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Wellington Care Center during CMS and state inspections, most recent first.
A resident with dysphagia and an order for a mechanically soft diet was served a regular texture meal instead of the ordered diet. While eating in the dining room, the resident choked on a meatball and required back thrusts and the Heimlich maneuver until the food was expelled. Interviews showed the RN had not been trained to verify tray tickets against meal tickets, and kitchen staff stated the wrong diet was served because the meal ticket was read incorrectly.
Kitchen sanitation, food storage, and menu substitution deficiencies: A DM and an employee with facial hair were observed with incomplete hair and beard coverage while working in the kitchen. Multiple food items in the freezer and cabinets were open to air, unsecured, unlabeled, undated, or expired. A planned pureed menu item was replaced with green beans for residents on pureed diets, but the substitution was not documented on the menu substitution list.
A resident with Alzheimer’s disease, dementia, weakness, and anxiety elected hospice care, but the facility did not complete the required SCSA within the required timeframe or afterward. The MDS LVN said she completed an Annual MDS instead and did not realize hospice enrollment required an SCSA; the DON said she was not familiar with MDS timing, and the Corp RN confirmed that hospice election requires a Significant Change in Status Assessment.
Improper Hand Hygiene During Catheter Care: A CNA failed to perform hand hygiene correctly while providing catheter and perineal care to a resident with dementia, BPH, flaccid neuropathic bladder, and an indwelling Foley catheter. The CNA removed gloves, handled clean wipes with ungloved hands, reused the wipes, and later touched a clean brief with contaminated gloves before placing it on the resident. The CNA acknowledged the contamination, and the DON and Corp RN stated staff are expected to clean hands before catheter care, when moving from dirty to clean tasks, and after glove removal.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with multiple medical conditions, including chronic kidney disease and urinary retention, was observed with an uncovered foley catheter bag hanging from the bed and touching the floor, in view of others. Staff interviews confirmed awareness that the lack of a privacy bag could cause embarrassment, and facility records showed both physician orders and care plans required the use of a privacy bag for the catheter.
Two residents with indwelling Foley catheters were observed with their catheter drainage bags in direct contact with the floor, contrary to their care plans and physician orders. Staff interviews confirmed knowledge of infection risks, but facility policies lacked specific guidance on catheter bag placement, resulting in a failure to implement proper infection prevention and control practices.
The facility failed to properly label, date, and store food, leading to potential food safety risks. Observations showed unlabeled and undated food in the freezer, moldy strawberries, and a dented can of mandarin oranges. Staff interviews revealed inconsistent practices in food labeling and removal of dented cans, despite monthly in-services. Facility policies from 2012 were not adhered to, posing a risk of foodborne illness.
The facility failed to provide a safe and comfortable environment for residents, with issues including a non-functional toilet shared by two residents and inadequate hot water access for three others. Despite complaints and attempts to address these issues, the problems persisted, affecting the residents' comfort and satisfaction.
A resident with moderately impaired cognition was not allowed to shower in the morning as per her preference due to staff shortages, causing inconvenience and annoyance. Despite the facility's policy on respecting resident rights, the resident was often told to wait until after lunch for her shower, which did not align with her preference.
Incorrect Diet Served, Resulting in Choking Event
Penalty
Summary
The facility failed to ensure that a resident with an order for a regular diet with mechanically soft texture received food prepared in the ordered form. The resident had diagnoses that included dysphagia and had a quarterly MDS indicating moderately impaired cognition. Her care plan directed staff to follow her prescribed diet and identified her as at risk for choking and malnutrition. The record also showed a prior choking event in which emergency services were called and the Heimlich maneuver was performed. On the evening of the incident, the resident was served a regular texture meal instead of the mechanically soft meal ordered by her physician. While eating in the dining room, she choked on a meatball. RN A responded, performed back thrusts, and then the Heimlich maneuver was performed several times until the meatball was expelled. The resident was documented as stable afterward, with normal assessment findings and clear lung sounds. Interviews and record review showed that RN A had been hired shortly before the event and stated she had not been trained to check meal trays against meal tickets to ensure residents received the correct diet. The DON stated RN A was supposed to check the meal ticket on the tray against the plate before the tray left the kitchen, but RN A did not realize that was her responsibility. [NAME] B stated she was rushing while reading meal tickets and that it was her fault the resident received a regular diet instead of the ordered mechanically soft diet. The facility’s investigation records and staff interviews confirmed that the incorrect diet was served and that the choking event occurred during the meal.
Kitchen sanitation, food storage, and menu substitution deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen. During observation, the Director of Maintenance had hair sticking out of her hairnet, and an employee with facial hair was observed wearing a beard cover that did not fully cover his beard or moustache. The employee stated he knew his beard and moustache needed to be covered, but the cover would not stay over his moustache. The Director of Maintenance acknowledged the hairnet issue and stated she had ordered different beard covers for him but had not received them. Food storage practices were also observed to be deficient. In the freezer and kitchen cabinets, multiple food items were found open to air, unsecured, or not in original packaging, including frozen bread, ham, hamburger patties, cookie dough, biscuits, rolls, cauliflower, Brussel sprouts, fish, lemon pie filling mix, pancake mix, and cream of wheat. Some items had no label or date, and several items were expired, including rolls, cauliflower, and Brussel sprouts with use-by dates of 1/19 and 1/26. The Dietary Manager stated she expected foods to be labeled, dated, and sealed, and that expired foods should be discarded. Menu substitution practices were not followed as written. The planned lunch menu included fried pickles for residents on pureed diets, but during preparation the fried pickles were not pureed and green beans were served instead. The Dietary Manager stated she decided not to puree the fried pickles because she did not think they would puree correctly. Review of the facility’s menu substitution list showed that the substitution of green beans for fried pickles had not been documented. The record also showed facility policies requiring hair restraints and beard covers, proper food labeling and storage, discarding expired foods, and documenting menu substitutions.
Failure to Complete Required SCSA After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment within 14 days after it determined that Resident #5 had a significant change in condition when she elected hospice care on 12/30/2024. Resident #5’s record showed diagnoses including Alzheimer’s disease, history of falling, muscle weakness, dementia, and generalized anxiety disorder. Her latest MDS was an Annual assessment completed on 10/30/2025, which documented severe cognitive impairment with a BIMS of 03 and indicated that she was receiving hospice care while a resident. Record review showed no Significant Change in Status Assessment was completed within 14 days of the hospice election or at any time after the hospice enrollment. The resident’s care plan reflected a terminal prognosis requiring hospice, and the facility’s hospice admission paperwork, progress notes, and physician orders confirmed hospice enrollment. During interview, the MDS LVN stated she completed the Annual MDS on 01/07/2025 and did not realize a Significant Change in Status Assessment was required when a resident elected hospice care; she confirmed the assessment should have been a SCSA. The DON stated she was not familiar with how to complete MDS assessments or the time frames, and the Corp RN stated that when a resident elected hospice, a Significant Change in Status Assessment was required.
Improper Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA A did not perform hand hygiene properly during catheter care for a resident with an indwelling Foley catheter. Resident #7 was a severely cognitively impaired male with diagnoses including dementia, benign prostatic hyperplasia, and flaccid neuropathic bladder. His care plan identified enhanced barrier precautions related to his catheter, and his orders included monthly Foley catheter changes. During observation, CNA A cleaned the resident’s perineal area and catheter tubing, then removed his gloves and retrieved more wipes with ungloved hands before washing his hands and putting on new gloves. He then used those wipes again to clean the catheter tubing. CNA A also assisted the resident with rolling, cleaned the buttocks and rectal area, touched a clean brief while wearing contaminated gloves, and then removed his gloves, washed his hands, put on new gloves, and placed the same brief on the resident. During interview, CNA A stated he contaminated the wipes by handling them before washing his hands and acknowledged he exposed the resident to infection, including a UTI or worse, by touching the brief with dirty gloves. The DON and Corp RN stated staff are expected to perform hand hygiene before catheter care, when moving from dirty to clean tasks, and after completing catheter care. Facility training and policies reviewed included handwashing, catheter care, perineal care, and hand hygiene after glove removal.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Maintain Privacy for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records by not maintaining the resident's foley catheter bag in a privacy bag as required by physician orders and the resident's care plan. During an observation, the resident was found lying in bed with the catheter bag hanging on the side of the bed, uncovered and touching the floor. This was witnessed by another resident who stopped in the doorway and looked into the room. The care plan specifically included an intervention to position the catheter bag and tubing below the level of the bladder and in a privacy bag, and the physician order required the foley bag to be in a privacy bag while the resident was in bed or a wheelchair during every shift. Interviews with staff, including CNAs and the DON, confirmed their awareness that not covering the catheter bag could embarrass residents and that the bag should be kept in a privacy bag. Review of facility policies on resident rights referenced the right to personal privacy, but the catheter care policy did not address the use of privacy bags for foley catheters. The resident involved had multiple diagnoses, including chronic kidney disease, urinary retention, and was on hospice care, requiring the use of an indwelling catheter.
Failure to Maintain Catheter Bag Placement and Infection Control
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents with indwelling Foley catheters. Observations revealed that both residents had their catheter drainage bags in direct contact with the floor. One resident's catheter bag was hanging on the side of the bed without a privacy cover, with the bottom of the bag touching the floor. The other resident's catheter bag was found lying flat on the floor under the bed and was visible from the doorway. Both residents had care plans and physician orders specifying that catheter bags should be kept off the floor and in privacy bags, but these interventions were not followed during the observed incidents. Record reviews indicated that both residents had significant medical histories, including chronic kidney disease, urinary retention, and neuropathic bladder, necessitating the use of indwelling catheters. Their care plans included specific interventions to prevent infection, such as maintaining the catheter bag off the floor, monitoring for signs and symptoms of urinary tract infection, and ensuring the use of privacy bags. Despite these documented interventions, staff failed to implement them as required. Interviews with staff, including CNAs and the DON, confirmed awareness of the risks associated with improper catheter bag placement, specifically the increased risk of infection. However, review of the facility's infection control and catheter care policies revealed no guidance regarding the need to keep catheter bags off the floor. This lack of policy detail, combined with observed staff inaction, contributed to the deficiency in infection prevention and control for residents with indwelling catheters.
Food Safety Deficiencies in Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper labeling, dating, and storage of food items. Observations revealed unlabeled and undated food items in the freezer, such as a resealable bag of breaded meat patties and open boxes of green peas and mixed vegetables. In the refrigerator, a basket of strawberries with mold and a container of cooked cauliflower were found, with the latter being dated three days prior. Additionally, a dented can of mandarin oranges was found in the pantry, and beef patties were improperly stored in the chest freezer with the plastic bag open, exposing the meat to air. Interviews with staff members, including the Dietary Manager (DM), Assistant Director of Nursing (ADON), and Licensed Vocational Nurse (LVN), highlighted a lack of consistent practices in labeling and dating food, as well as removing dented cans from circulation. The DM acknowledged that all kitchen staff were responsible for these tasks and mentioned that in-services were conducted monthly, although records showed limited training on relevant topics. The facility's policies from 2012 outlined proper food handling and storage procedures, but these were not followed, leading to potential risks of foodborne illness for residents.
Deficiencies in Toilet Functionality and Hot Water Access
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, specifically concerning the functionality of toilets and access to hot water. Resident #7 and Resident #20 experienced issues with a toilet that did not flush properly. Despite complaints to staff, including maintenance personnel, the issue persisted for an extended period. The toilet in their shared room required multiple flushes to function, causing frustration and inconvenience for the residents. The problem was acknowledged by the facility, but the resolution was delayed, leading to dissatisfaction among the residents. Additionally, three anonymous residents reported a lack of hot water in their rooms and showers. The residents expressed dissatisfaction with the water temperature, which was either cool or took an extended time to warm up. The facility had been aware of the hot water issue for about a month, having replaced a hot water heater and consulted plumbers, but the problem remained unresolved. The water temperature varied significantly depending on the room's proximity to the water heater, with some rooms not reaching the desired temperature. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and Maintenance Staff (MS), confirmed awareness of the issues. The facility's plumbing system, described as a U-shape, contributed to the inconsistent water temperatures. Despite attempts to address the problems, such as installing a new water heater and pump, the issues persisted, affecting the residents' comfort and satisfaction with their living environment.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not allowing Resident #22 to shower in the morning as per her preference. Resident #22, a female with moderately impaired cognition and a history of strokes, expressed her desire to shower in the morning. Despite her preference, the facility's records showed that 5 out of 7 showers in October were scheduled in the afternoon. During an interview, Resident #22 stated that she was often told by staff that they were too busy in the mornings, requiring her to wait until after lunch for her shower. This situation caused her inconvenience and annoyance, as she had to change her clothes multiple times. Interviews with facility staff, including a CNA, ADON, LVN, and DON, revealed that the facility was short-staffed at times, leading to residents being asked to wait for showers. The ADON and DON did not perceive a negative outcome from delaying showers, as long as they were completed the same day. However, the CNA acknowledged that residents had to wait when the facility was short-staffed. The facility's policy on resident rights emphasized the importance of treating each resident with respect and recognizing their dignity and individuality, which was not upheld in this instance.
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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.
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Nursing homes near Wellington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memphis Convalescent Center | 20.2 mi | ★★★★★ | 4 | 0 |
| Colonial Manor Ii | 20.4 mi | ★★★★★ | 2 | 0 |
| Avir At Childress | 28.6 mi | ★★★★★ | 4 | 0 |
| Mclean Care Center | 34.5 mi | ★★★★★ | 1 | 1 |
| Clarendon Nursing Home | 38.4 mi | ★★★★★ | 5 | 0 |
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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.