Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, aphasia, hemiplegia, and a documented history and care plan for elopement risk became agitated when a usual coffee routine was missed. While a housekeeper took trash out and failed to ensure the back gate locked, the resident caught the door, exited in a wheelchair into the alley behind the facility, and attempted to proceed toward a nearby coffee shop. Staff were alerted by another resident, found the resident in the alley attempting to cross, and encountered agitation and combative behavior, including the resident striking an LVN, before successfully returning the resident inside. This sequence of events reflects a failure to maintain a secure environment and provide adequate supervision for a known elopement-risk resident.
The facility did not coordinate assessments with the PASRR program or refer residents for necessary services as required.
A resident with severe cognitive impairment and high fall risk was transferred by a CNA without a gait belt and without the required second staff member, resulting in a femur fracture that required surgery. The CNA performed the transfer from behind the resident, contrary to facility policy and standard practice, and did not consult the Kardex for transfer requirements.
A nurse aide failed to use a gait belt and proper positioning during a one-person transfer of a resident who required substantial/maximal assistance, resulting in the resident falling and sustaining a femoral fracture. The resident had multiple diagnoses, was a high fall risk, and required two-person assistance for transfers per care plan. The aide did not consult the Kardex for transfer requirements and did not follow established protocols, leading to the incident.
A resident with severe cognitive impairment and mobility deficits sustained a femur fracture during a transfer by a CNA who did not use a gait belt. The facility did not thoroughly investigate the incident, failed to document staff statements, and did not ensure all required investigative steps were followed according to policy.
A resident with mental health diagnoses did not receive an accurate PASARR Level 1 screening, and the facility failed to notify the local authority as required. Documentation showed the resident had a mental illness, but the necessary follow-up and notification were not completed according to facility policy.
A resident with severe cognitive impairment eloped from the facility and attempted to shoplift at a local grocery store. The resident's care plan lacked evidence of wandering or elopement risk, contributing to inadequate supervision. The incident occurred when the resident slipped out unnoticed through the front door, highlighting a lapse in the facility's implementation of its wandering and elopement policy.
A resident with an indwelling urinary catheter did not receive appropriate catheter care due to a failure in implementing batch orders upon admission. The DON admitted to the oversight, citing a lack of training and awareness among staff regarding batch order input. The facility's policy required daily catheter care, but this was not documented for over a week, raising concerns about potential health risks.
A resident with mild cognitive impairment and multiple health conditions was physically abused by an LVN who pulled the resident's wheelchair, causing a fall. The incident was observed by the DON, and the resident refused further assessment. The LVN, despite having received training on resident rights, was terminated after a facility investigation confirmed the abuse.
The facility failed to notify a resident's physician of significant constipation until the fifth day, despite the resident's condition not improving with administered treatments. The resident was eventually sent to the hospital and diagnosed with SIRS, cellulitis, and wheezing. Interviews revealed that the NP was not informed of the condition until the day of hospitalization, contrary to the facility's policy.
Elopement of High-Risk Resident Through Unsecured Back Gate
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accidents for a cognitively impaired resident with known elopement risk, resulting in an elopement from the building. The resident was a 60-year-old male with diagnoses including cerebral infarction, COPD, asthma, hemiplegia, hemiparesis, aphasia, and depression. His quarterly MDS showed a BIMS score of 01, indicating severe cognitive impairment and that he was not interviewable. His care plan, dated 11/12/2025, identified him as having potential for behavioral problems and impulsiveness and specifically documented him as an elopement risk with a history of elopement from a previous nursing facility, with interventions such as assessing fall risk, redirecting, documenting wandering behaviors, and providing structured activities. On the day of the incident, the resident became agitated when a fill-in receptionist failed to obtain his usual coffee from a local coffee shop across the street, which staff had previously been bringing to him. During this time, the housekeeper took trash out to the dumpster through the back gate and failed to ensure that the gate locked behind her. The back patio area was described as a secure locked area with a long alleyway directly behind the facility. Because the gate did not lock, the resident was able to catch the door and roll his wheelchair out of the gate toward the alley in an attempt to get to the coffee shop located at the end of the alley. Staff became aware of the elopement when another resident reported that the resident had gone out of the back gate. The housekeeper reported that she then yelled the facility’s elopement code and ran outside, where a nurse was already present with the resident. An LVN and a CMA both reported that when they reached the resident in the alley, he had locked his wheelchair, was attempting to cross the alley, and became agitated and combative when they tried to redirect him back inside, striking the LVN in the face. The LVN stated she was only able to complete a range of motion assessment due to his aggression, while the ADON documented completing a head-to-toe assessment, change in condition assessment, smoking evaluation, and elopement risk assessment. The facility’s elopement policy stated that the facility would provide a safe environment as free of accidents as possible through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement, but the resident’s elopement occurred despite his known risk and care plan.
Removal Plan
- In-services for all staff on de-escalation, elopement, elopement binder location, and ensuring the gate closes completely and locks
- Documented door checks performed by the maintenance manager
- Elopement behavior quiz
- Positioned a staff member to sit at the back door
- Having a wander guard system installed
- Repaired/adjusted the gate lock so it clicks/locks once closed
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Safe Transfer Leading to Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including vascular parkinsonism, dementia, muscle weakness, and severe cognitive impairment, was not provided with adequate supervision and assistive devices during a transfer. The resident was assessed as a high fall risk, required substantial/maximal assistance for transfers, and had a care plan indicating the need for staff participation during transfers. However, the care plan did not specify the use of a gait belt for transfers. The resident's transfer needs were documented in the Kardex, but this information was not reviewed prior to the incident due to the resident's discharge. On the day of the incident, a CNA attempted to transfer the resident using a stand and pivot method without the use of a gait belt and performed the transfer alone, standing behind the resident rather than in front as per facility policy and standard practice. During the transfer, the resident's leg slid, and the CNA helped the resident to the ground, resulting in the resident falling forward to his knees. The resident sustained a right femoral shaft fracture, which required surgical intervention. Interviews with staff and therapy personnel confirmed that transfers should always be performed with a gait belt, with staff positioned in front of the resident, and that substantial/maximal assistance requires two staff members. The CNA involved stated she did not use a gait belt because she was not told it was needed and typically transferred the resident from behind, which was not consistent with facility policy or standard practice. Other staff interviews confirmed that the correct procedure was not followed, and that the Kardex should be used to determine transfer requirements. The incident was identified as an Immediate Jeopardy situation due to the failure to provide adequate supervision and assistive devices, resulting in a serious injury to the resident.
Failure to Ensure Competent Resident Transfer Leading to Injury
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in the skills and techniques necessary to safely transfer a resident, as identified through resident assessments and described in the plan of care. Specifically, a nurse aide did not use a gait belt, did not position herself correctly, and attempted a one-person transfer for a resident who required substantial/maximal assistance, which typically necessitates two staff members. The aide stood behind the resident during the transfer, contrary to facility policy and standard practice, and did not verify the resident's transfer requirements in the Kardex prior to the transfer. The resident involved was an elderly male with multiple diagnoses, including vascular parkinsonism, atrial fibrillation, dysphagia, unsteadiness, muscle weakness, intellectual disabilities, and dementia. He was assessed as a high fall risk, had severe cognitive impairment, and required substantial/maximal assistance for transfers according to his care plan and MDS. On the day of the incident, the aide attempted to transfer the resident from bed to wheelchair using a stand-and-pivot method without a gait belt and without a second staff member. During the transfer, the resident's leg slid, and he was assisted to the ground by the aide, resulting in a fall. Following the incident, the resident was found to have right hip tenderness, swelling, and severe pain, and was subsequently transferred to the hospital where he was diagnosed with a right femoral shaft fracture requiring surgical intervention. Interviews with other staff and therapy personnel confirmed that the standard procedure was to use a gait belt and have staff positioned in front of the resident during transfers, and that substantial/maximal assistance required two staff members. The aide involved did not follow these procedures, and her actions were inconsistent with both facility policy and her prior training.
Failure to Investigate and Prevent Further Harm After Resident Fall
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for one resident. Specifically, a resident with severe cognitive impairment, multiple comorbidities including vascular parkinsonism, dementia, and significant mobility deficits, sustained a femur fracture during a transfer performed by a CNA. The resident required substantial to maximal assistance for transfers and was at risk for falls, as documented in the care plan. On the day of the incident, the CNA attempted a stand and pivot transfer without using a gait belt, contrary to facility expectations. The CNA reported that the resident's leg slid and she helped him to the ground, after which the resident was found to have right hip tenderness, swelling, and severe pain, leading to a hospital transfer where a femoral shaft fracture was diagnosed. There was no documentation of statements from the CNA or the LVN present at the time of the fall, and no Post-Incident Report (PIR) was provided for the event. Interviews with facility leadership revealed a lack of clarity regarding the specifics of the transfer, including whether a gait belt was used and the CNA's positioning. The Director of Nursing and Administrator were not fully aware of the details and did not ensure a thorough investigation was conducted as outlined in the facility's abuse prevention policy, which requires interviews with all involved parties and documentation of the investigation's results. The absence of a comprehensive investigation and documentation following the incident constituted the deficiency.
Failure to Complete and Notify PASARR Screening for Mental Health Disorder
Penalty
Summary
The facility failed to ensure that a resident with mental health disorders received an accurate PASARR Level 1 screening and that the local authority was notified as required. Record review showed that the resident, a female with diagnoses including post-traumatic stress disorder and bi-polar disorder in full remission, had a PASARR Level 1 screening indicating the presence of a mental illness, intellectual disability, or developmental disability. Despite this, there was no evidence that the facility notified the local authority or obtained a PASARR Level II evaluation as required by policy. Interviews with facility staff confirmed that the MDS Coordinator is responsible for completing and modifying the MDS and PASARR screenings, and that failure to submit the PASARR in a timely manner could result in the resident not receiving necessary services. The facility's policy requires follow-up on all residents with positive PASARR Level I screenings, including obtaining a Level II evaluation or documenting attempts to do so, but this process was not followed for the resident in question.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. This deficiency was highlighted by the incident involving a resident who eloped from the facility. The resident, who had a severe cognitive impairment with a BIMS score of 05, managed to leave the facility unnoticed and went to a local grocery store where he attempted to shoplift steaks. The resident's medical history included conditions such as nontraumatic intracerebral hemorrhage, essential hypertension, and cerebral infarction, among others, which could have contributed to his cognitive impairment and wandering behavior. The incident occurred when the resident slipped out of the facility through the front door while the receptionist was occupied with assisting someone else. The resident's departure went unnoticed until a nurse realized he was missing during lunchtime. Despite the resident's severe cognitive impairment, his care plan did not include any evidence of wandering or risk for elopement, which contributed to the lack of adequate supervision and preventive measures. Staff interviews revealed that the resident had expressed intentions to obtain steaks, which was overheard by a CNA. However, this information was not acted upon in a timely manner to prevent the elopement. The facility's policy on wandering and elopement was not effectively implemented, as evidenced by the resident's ability to leave the premises without detection. The incident was only resolved after the resident was found and returned to the facility, highlighting a significant lapse in supervision and environmental safety measures.
Failure to Provide Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, a female with multiple diagnoses including chronic kidney disease and congestive heart failure, was admitted to the facility with a Foley catheter. Despite the presence of the catheter, the facility did not implement a batch order for daily catheter care upon her admission, and no catheter care was documented from July 2, 2024, to July 10, 2024. The Director of Nursing (DON) acknowledged the oversight, stating that the batch orders for catheter care were not entered until July 10, 2024, due to a delay in processing. The DON admitted that the nurses were still learning how to input batch orders and that she was ultimately responsible for ensuring they were completed. Interviews with staff, including the Assistant Director of Nursing (AD) and the Medical Director (MD), revealed a lack of awareness and training regarding the input of batch orders for catheter care, contributing to the oversight. The facility's policy required daily catheter care to promote hygiene and reduce infection risk, but this was not adhered to for the resident in question. The absence of documented catheter care raised concerns about potential risks to the resident's health, although the report does not specify any direct consequences that occurred as a result of this deficiency.
Resident Abuse by LVN in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically an LVN, on June 3, 2024. The incident involved the LVN pulling on the resident's wheelchair, causing the resident to fall to the ground. This action was observed by the Director of Nursing (DON), who noted that the LVN was speaking loudly to the resident and pulling on the wheelchair, resulting in the resident falling to his knees. The resident refused a skin assessment afterward and denied any pain, expressing a desire to rest and not be touched by staff. The resident involved was a male with a history of Alzheimer's Disease, Type 2 Diabetes, Asthma, Dementia, Hypertension, and Osteoporosis. His quarterly MDS assessment indicated a BIMS score of 11, suggesting mild cognitive impairment, and he was able to ambulate independently using a wheelchair. The resident's care plan, which was canceled on June 27, 2024, highlighted a potential for injury due to the incident and included interventions such as monitoring for changes in behavior or mood and referring to psychology and psychiatry services. The facility's investigation revealed that the LVN had been trained on resident rights and protections, including preventing abuse, neglect, and mistreatment. Despite this training, the LVN was observed on video pulling the resident's wheelchair, leading to the resident's fall. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and neglect, and it prohibits staff from engaging in actions that demean or humiliate residents. The LVN was suspended immediately following the incident, and the decision was made to terminate the LVN after reviewing the video footage.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status. Specifically, the facility did not inform the nurse practitioner (NP) about a resident's constipation until the fifth day of the condition. The resident, a [AGE] year-old female with diagnoses including irritable bowel syndrome, chronic pain, morbid obesity, and panic disorder, did not have a bowel movement from 04/21/24 until 04/25/24. Despite receiving stool softeners, MiraLAX, lactulose, and prune juice, the resident's condition did not improve, and she eventually requested to be sent to the hospital, where she was diagnosed with SIRS, cellulitis of the left leg, and wheezing. The issues resolved during hospitalization included cellulitis, constipation, and SIRS. Interviews with the resident, LVNs, and the NP revealed that the NP was not notified of the resident's constipation until the day she was sent to the hospital. The facility's Change of Condition Policy requires that any change in a resident's condition, including bowel movements, be reported to the licensed nurse or nurse supervisor and that the interdisciplinary team collaborate with the attending physician. The Director of Nursing (DON) confirmed that it was the nurses' responsibility to notify the NP of any changes to ensure she was involved in all aspects of the residents' care. The failure to notify the NP in a timely manner placed the resident at risk of illness and decreased quality of life.
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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 Temple
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baylor Scott & White Continuing Care Hospital Skil | 0.5 mi | ★★★★★ | 1 | 0 |
| Avir At Weston | 0.6 mi | ★★★★★ | 3 | 0 |
| William R Courtney Texas State Veterans Home | 1.3 mi | ★★★★★ | 3 | 0 |
| Avir At Temple West | 1.4 mi | ★★★★★ | 1 | 0 |
| Avir At Temple East | 1.4 mi | ★★★★★ | 3 | 0 |
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