Wellington Place

In the surveyor’s words

From the most serious findings on record at Wellington Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF755Aug 10, 2023

  Based on clinical record review, document review, policy review, physician, pharmacy, and staff interviews, the facility failed to have a system in place to ensure medication orders were received from the pharmacy. This failure resulted in a physician ordered diuretic medication not being administered for 1 of 3 residents sampled (Resident #42). Resident #42 went into fluid overload (a condition where there is too much fluid volume in the body that can cause high blood pressure, swelling, and heart problems) and atrial fibrillation (irregular and often very rapid heart rhythm) which required direct admission to the hospital therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. […]

• Actual harm, isolatedF760Aug 10, 2023

  Based on clinical record review, document review, policy review, physician, pharmacy, and staff interviews, the facility failed to administer a diuretic medication as physician ordered. This failure resulted in a significant medication error for 1 of 3 residents sampled (Resident #42). Resident #42 went into fluid overload (a condition where there is too much fluid volume in the body that can cause high blood pressure, swelling, and heart problems) and atrial fibrillation (irregular and often very rapid heart rhythm) which required direct admission to the hospital. The facility identified a census of 44 residents. Findings include: Resident #42 MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. […]

• No harm, potential for more than minimal, patternF812Aug 10, 2023

  Based on observation and staff interview the facility failed to serve plates without touching food surfaces and a glass by the drinking surface for 39 residents served the noon meal on 8/8/23. The facility reported a census of 44 residents. Findings include: During an observation of the noon meal on 8/7/23, Staff F, dietary aide was observed handling drinking glasses by the top of the glass, touching the drinking surface of the glass. During an observation of the noon meal on 8/8/23 Staff A, cook was observed plating the resident meals. During the observation, all resident plates (regular plates and adaptive plates) and bowls used to serve residents were touched on or in the food surface area prior to putting food on the plate or in the bowl. […]

• No harm, potential for more than minimal, patternF882Oct 18, 2021

  Based on staff interviews and review of guidance from the Centers for Disease Control, the facility failed to have an Infection Preventionist trained in infection prevention and control on staff. The facility reported a census of 42 residents. Findings include: During an interview with Staff A, Administrator on 10/18/21 at 11:20 a.m., the Administrator indicated they currently do not have an Infection Preventionist on staff. The former trained Infection Preventionist Nurse left employment on 7/28/21 but Staff D, RN (Registered Nurse) Nurse Consultant is performing this role. Staff D comes to the facility two to three times a week to cover this since the former nurse left. […]

• No harm, potential for more than minimal, isolatedF867Apr 28, 2022

  Based on record review, facility policy review, and staff interview, the facility failed to ensure the Medical Director attended Quality Assurance (QA) meetings at least quarterly as required. The facility reported a census of 42 residents. Findings include: Review of the monthly QA meeting attendance sign in sheets from February 2021 to March 2022 revealed the facility Medical Director attended the QA meeting held in December of 2021 and the meeting held in March of 2022. The monthly QA sign in sheets for June of 2021 and August of 2021 contained the Medical Director's signature both with the note Reviewed 9/3/21 indicating they did not attend those meetings but reviewed the minutes and no other monthly sign in sheets contained the Medical Director's signature. […]