Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure 3 of 3 sampled residents were spoken to and cared
for in a dignified manner (Residents #18, #39, and #33).
The findings included:
1) Review of the record revealed Resident #18 was admitted to the facility on [DATE]. Review of the current
Minimum Data Set (MDS) assessment dated [DATE] documented the Resident #18 had a Brief Interview
for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact.
Review of the current orders revealed the resident had an admission order dated 08/30/24 for the use of
barrier cream, a protective cream, every shift and as needed. A secondary order was written on 09/01/24 to
clean the buttock with normal saline and apply zinc oxide every shift. This order was typically used when a
resident has excoriation to the buttock.
During an interview on 09/24/24 at 10:33 AM, when asked if she was treated with dignity and respect,
Resident #18 stated with some of the staff it's like they don't care. Resident #18 explained her bottom was
raw from a week in the hospital and a week at the facility. Resident #18 stated, The other night it hurt when
she, a Certified Nursing Assistant (CNA) was cleaning me up. She had me almost in tears, and I told her it
hurt, and she just kept doing the same thing. I don't think she was intentionally trying to hurt me, but she
just wasn't listening or caring. When asked if she had told anyone about her concerns, she stated, No one
comes around to see how we are doing. When asked if they do daily rounds to see you and see how you
are doing, Resident #18 stated, No, I don't think they have time for that. Resident #18 stated she can hear
staff talking to the resident across the hall, to include staff statements like, I'm busy. You'll have to wait. You
don't need that right now. I'm not getting you that now. During the continued interviewed, when asked about
therapy, Resident #18 stated one of the therapists speaks down to me. When asked what she meant by
that, the resident stated, I don't know if she thinks I don't understand, but she tries to force me to do
something when she wants it done. The resident gave the example that she could be in the middle of eating
and the therapist will see the red exercise band hooked on the side of her bed and say, let's do it now,
referring to the exercises, even though she was still eating. Resident #18 stated, She just talks and thinks
right over me.
2) Review of the record revealed Resident #39 was admitted to the facility on [DATE]. Review of the current
MDS dated [DATE] documented the resident had a BIMS score of 15 and was dependent upon staff for
toileting.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
106091
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 09/25/24 at 3:59 PM, Resident #39 explained that morning, after being taken to the
bathroom, she was having trouble cleaning herself. She called for assistance and the CNA was very abrupt
with her. The resident explained she was standing up and needed help. The CNA asked her multiple times,
what do you need with a tone in her voice. The resident stated then the CNA kept telling her Move your leg
two or three times, while the resident was saying I'm trying to but can't. The resident stated, It's just not
respectful. During this same interview, Resident #39 stated therapy dropped her off in her room that
afternoon, placing her next to the bed. The resident stated a little later she needed to use the bathroom,
and the call light was on the other side of her bed out of reach. The resident stated she had to start
screaming to get anyone in the room to assist her. Resident #39 stated staff will often come in and shut the
light off and say they will be back. After 45 minutes or so she would have to call them back. The resident
stated she had been left in a soiled diaper for over an hour.
3) Review of Record revealed Resident #33 was admitted to the facility 08/26/24.
Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #33 had
a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was
cognitively intact.
During an interview on 09/23/24 at 2:47 PM, Resident #33 was observed to be visibly upset. When asked
about her care, the resident stated the care could be better. She stated there were some disrespectful staff
that took care of her. She explained they roll their eyes when she asked for help. When asked how that
made her feel, the resident stated, It is upsetting.
During an Interview on 09/27/24 at 11:05 AM, when Resident #33's concerns were addressed with the
Administrator and Social Service Assistant, they agreed the resident was not treated in a dignified manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 2 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews and record reviews, the facility failed to ensure adequate staff communication with 2
of 2 sampled residents who were unable to speak English (Resident #29 and #394).
Residents Affected - Few
The findings included:
1) A review of the Electronic Health Record documented Resident #29 was admitted to the facility on
[DATE] with diagnoses which included Major Depressive Disorder, Need for Assistance with Personal Care,
and Difficulty in Walking,
A review of the 5 day Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #29
has a BIMS (Brief Interview for Mental Status) score of 7 out of 15 (cognitively impaired). It also
documented in Section A of the MDS that the resident is of Hispanic origin and her preferred language is
Spanish. It also documents her desire to have an interpreter to communicate with a doctor or health care
staff.
On 09/23/24 at 11:01 AM, an attempt was made to interview Resident #29, but she was unable to
understand English. Her [family member] who was in the room at the time and states that she visits
frequently, complained, [Resident #29] only speaks Spanish and there are no care staff available who
speak Spanish. There is no way for [Resident #29] to communicate her needs to the staff, or for the staff to
communicate with [Resident #29]. There should be something they can use to communicate. There are
apps on the phones that will translate, but I haven't seen any care staff using them to communicate with
[Resident #29].
2) A review of the record revealed Resident #394 was admitted to the facility on [DATE].
A review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #394
had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was
cognitively intact. This same MDS section A Identification Information documented the resident was of
Hispanic, Latino or Spanish origin. The MDS documents the resident's preferred language as Spanish and
her need/want of an interpreter to communicate with a doctor or health care staff.
Two observations on 09/25/24 at 9:30 AM and 09/25/24 at 11:40 AM were made of staff interacting with
Resident #394 in English.
During an interview on 09/23/24 at 12:00 PM conducted in Spanish, when asked how she communicated
with staff, Resident #394 stated she cannot communicate with staff and had not been offered any
communication system such as the use of a language line.
During an interview on 09/25/24 at 11:12 AM, when asked how the care of Resident #394 was, the family
member stated there is no diversity here. Before the resident's admission to the facility, she was told there
were Spanish personnel at the facility. During the last care plan meeting the family member was told that
nurses were trilingual, she stated this was not true because they're not able to communicate with the
resident. When asked if staff use a language line or any type of communication system, she stated they do
not.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 3 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0676
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 09/27/24 at 9:51 AM, when asked how many Spanish speaking nurses and Certified
Nursing Assistants (CNA) were available in the facility, the Staffing Coordinator stated they had one
Spanish speaking CNA during the day shift and one during night shift. She stated they had two Spanish
speaking nurses during the day.
During an interview on 09/27/24 at 9:57 AM, when asked how staff communicated with Spanish speaking
residents, the MDS Coordinator stated they call nurses, CNAs, or Spanish speaking staff to translate for
residents.
During an interview on 09/27/24 at 10:52 AM, when asked what staff should do when there is no Spanish
speaking staff available, the Administrator and Social Service Assistant stated they should use the
language line. The Surveyor was provided with evidence of the language line instructions of how to access
an interpreter the facility staff is expected to utilize. (Photographic evidence obtained).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 4 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure timely administration of two prescribed medications
for 1 of 6 sampled residents reviewed for medications (Resident #50).
Residents Affected - Few
The findings included:
Record review revealed that Resident #50 was admitted on [DATE] with diagnoses which included
Parkinson's Disease, Syncope and Collapse, Orthostatic Hypotension, and Hypertension.
A review of Resident's 5-day Minimum Data Set (MDS) assessment dated [DATE] documented that the
resident had a BIMS score of 15 out of 15 (cognitively intact).
On 09/24/24 at 9:45 AM, during an interview with Resident #50, she stated that she has run out of her
medications a couple of times for 1-2 days. She stated she didn't want to speak about it further but provided
the surveyor with her samily members number and asked that he be interviewed for further details.
On 09/24/24 at 11:49 AM, Resident #50's family member was interviewed via telephone and stated that he
felt Resident #50 had declined due to not participating in therapy as much as she needed to because she
was not being provided her medications in a timely manner. When she doesn't get her medications on time,
it can affect her blood pressure, she becomes dizzy, and she doesn't want to get out of bed to attend
therapy.
On 09/27/24 at 3:17 PM, an interview was conducted with the Assistant Director of Rehab/Physical Therapy
Assistant. He stated, [Resident #50] is currently receiving PT/OT and is scheduled for 5 days, but there
have been some refusals due to dizziness.
A review of Resident #50's Care Plan, initiated on 08/30/24, documents that the resident has an alteration
in neurological status due to diagnosis of Parkinson's, and the resident's prescribed medications are to be
given as ordered.
A review of Resident #50's medication orders showed active orders for the following Parkinson's
medications:
Carbidopa-Levodopa Oral Tablet 25-100 MG Give 1 tablet by mouth three times a day for Parkinson (9 AM,
1 PM, and 5 PM); and
Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG Give 1 tablet by mouth two times a day
for Parkinson (6 AM and 9 PM).
A review of the Medication Administration Record revealed the following for the administration of
Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG (8 AM and 8 PM):
09/08/24 - medication was not recorded as being given at 8 AM.
09/14/24 - medication was given at 10:09 PM (1 hour and 9 minutes late);
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 5 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0684
09/16/24 - medication was given at 11:10 PM (2 hours and 10 minutes late);
Level of Harm - Minimal harm
or potential for actual harm
09/25/24 - medication was given at 10:09 PM (1 hour and 9 minutes late).
A review of the Medication Administration Record revealed the following for the administration of
Residents Affected - Few
Carbidopa-Levodopa Oral Tablet 25-100 MG (9 AM/900, 1 PM/1300, and 5 PM/1700):
09/20/24 - medication was given at 10:49 AM (1 hour and 49 minutes late);
09/20/24 - medication was given at 2:25 PM (1 hour and 25 minutes late);
09/21/24 - medication was given at 10:07 AM (1 hour and 7 minutes late);
09/22/24 - medication was given at 10:26 AM (1 hour and 26 minutes late);
09/22/24 - medication was given at 10:09 PM (1 hour and 9 minutes late);
09/24/24 - medication was given at 6:14 PM (1 hour and 14 minutes late);
09/26/24 - medication was given at 11:53 AM (2 hours and 53 minutes late);
09/26/24 - medication was given at 3:19 PM (2 hour and 19 minutes late);
09/27/24 - medication was given at 11:21 AM (2 hours and 21 minutes late);
09/27/24 - medication was given at 3:02 PM (2 hours and 2 minutes late).
On 09/27/24 at 4:37 PM, an interview was conducted with the Director of Nursing (DON). She confirmed
that medications are to be given within 1 hour prior and 1 after the prescribed time of the medication, per
physician order. The DON was provided evidence showing Resident #50's medications have not
consistently been provided within the allowed time frames. The DON stated she would start an in-service
for nursing staff regarding providing the residents with their medications in a timely manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 6 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure sufficient staffing as evidenced by
failure to provide timely administration of medications for 1 of 6 sampled residents (Resident #50 .refer to
F684); ineffective communication for 2 of 2 sampled residents (Residents #29 and 394 (refer to F676); and
numerous resident / family complaints from 13 of 31 sampled residents / representatives (Residents #394,
#393, #192, #39, #66, #33, #4, #29, #193, #63, #1, #194, and #395).
The findings included:
1) On 09/24/24 at 11:49 AM, Resident #50's family member was interviewed via telephone and stated that
he felt [Resident #50] had declined due to not participating in therapy as much as she needed to because
she was not being provided her medications in a timely manner. When she doesn't get her medications on
time, it can affect her blood pressure, she becomes dizzy, and she doesn't want to get out of bed to attend
therapy.
A review of Resident #50's medication orders showed active orders for the following Parkinson's
medications:
Carbidopa-Levodopa Oral Tablet 25-100 MG Give 1 tablet by mouth three times a day for Parkinson (9 AM,
1 PM, and 5 PM); and
Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG Give 1 tablet by mouth two times a day
for Parkinson (6 AM and 9 PM).
A review of the Medication Administration Record revealed the following for the administration of
Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG (8 AM and 8 PM):
09/08/24 - medication was not recorded as being given at 8 AM.
09/14/24 - medication was given at 10:09 PM (1 hour and 9 minutes late);
09/16/24 - medication was given at 11:10 PM (2 hours and 10 minutes late);
09/25/24 - medication was given at 10:09 PM (1 hour and 9 minutes late).
A review of the Medication Administration Record revealed the following for the administration of
Carbidopa-Levodopa Oral Tablet 25-100 MG (9 AM/900, 1 PM/1300, and 5 PM/1700):
09/20/24 - medication was given at 10:49 AM (1 hour and 49 minutes late);
09/20/24 - medication was given at 2:25 PM (1 hour and 25 minutes late);
09/21/24 - medication was given at 10:07 AM (1 hour and 7 minutes late);
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 7 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0725
09/22/24 - medication was given at 10:26 AM (1 hour and 26 minutes late);
Level of Harm - Minimal harm
or potential for actual harm
09/22/24 - medication was given at 10:09 PM (1 hour and 9 minutes late);
09/24/24 - medication was given at 6:14 PM (1 hour and 14 minutes late);
Residents Affected - Some
09/26/24 - medication was given at 11:53 AM (2 hours and 53 minutes late);
09/26/24 - medication was given at 3:19 PM (2 hour and 19 minutes late);
09/27/24 - medication was given at 11:21 AM (2 hours and 21 minutes late);
09/27/24 - medication was given at 3:02 PM (2 hours and 2 minutes late).
On 09/27/24 at 4:37 PM, an interview was conducted with the Director of Nursing (DON). She confirmed
that medications are to be given within 1 hour prior and 1 after the prescribed time of the medication, per
physician order. The DON was provided evidence showing Resident #50's medications have not
consistently been provided within the allowed time frames.
2) On 09/23/24 at 11:00 AM, the family member of Resident #29 stated, [Resident #29] only speaks
Spanish and there is no staff available that speaks Spanish. I am concerned because there is no way for
[Resident #29] to communicate with the staff. The family member also added, There needs to be more
supervision. Staff do not come by and check on [Resident #29] very often. The response time to her call
light is very long.
On 09/23/24 at 11:46 AM, Resident #394, who has a Brief Interview for Mental Status (BIMS) score of 14,
complained there is not enough staff. I ring the call light, and it takes about 20 minutes to respond. When I
go to the bathroom, it takes 20 minutes or longer to get changed. It is often that this happens. It happens
more at night.
On 09/25/24 at 11:12 AM, during interview with Resident #394's family member, she stated she does not
think there is sufficient staff to meet [Resident #394's] needs. There are no Spanish speaking personnel
able to communicate with [Resident 394]. Before admission, they were told that there were
Spanish-speaking personnel, and during the care plan meeting, they were told that nurses were trilingual,
but they are not. The family member added, I have had to come into the facility to change [Resident #394]
since staff were not answering the call light. No one was at the nurse's station to take my calls. I left
messages, and no one return the calls. I asked the social worker during the care plan meeting where my
voicemails were going, and I was told that she didn't know. No one is at the desk at night. I feel the staff are
overwhelmed at night.
3) The following concerns were voiced by residents and family members during the survey process:
a) On 09/23/24 at 11:15 AM, Resident #192, whose BIMS is 12, stated, The staff response time to call my
light is long. It usually takes an hour for staff to respond.
b) On 09/24/24 at 9:50 AM, Resident #194, whose BIMS is 15, stated, I ask staff for a cup of ice and
gingerale, but they tell me they don't have soda and never provide it to me. I have also asked staff 2 days
ago for some Ben Gay to rub on my shoulder, and still nothing. I asked for some lotion for my back 3 days
ago, and I have not received it. The staff keep saying 'OK, OK', but they never do
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 8 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0725
anything.
Level of Harm - Minimal harm
or potential for actual harm
c) On 09/23/24 at 10:50 AM, Resident #193, whose documented BIMS is 15, stated, Usually, there is only 1
nurse on the floor at times. The fastest response time is 25-30 minutes. Usually, it is 2-3 hours before staff
answer my call light.
Residents Affected - Some
d) On 09/23/24 at 2:35 PM, Resident #63, with a BIMS score of 11, indicating moderate cognitive
impairment, stated there is not enough staff; she waits 2 & 1/2 hours to get changed.
e) On 09/23/24 at 2:25 PM, Resident #71, who has a BIMS score of 13 said it feels like they are short
staffed. There are long wait times to get changed, at least 2-3 times it has been over an hour.
f) On 09/23/24 at 10:36 AM, Resident #393, whose BIMS score was 15 and was admitted on [DATE],
stated that she had sat in soiled briefs for 5 hours, as she had watched clock. Her family member, who was
at bedside, tried to help. The aide, who was unpleasant, told her, 'This is the 2nd time I have to change
you'. The family added that [Resident #393] was not provided water and stated that this all occurred during
the weekend. It was hard to find any staff to help. It was stated that on Friday night, a random resident
walked into Resident #393's room and sat on her floor. The resident was very sweet, but it was a little
frightening.
g) On 09/23/24 at 12:12 PM, Resident # 66's representative said that this resident did not get changed and
dressed until 11:30 AM today. She stated that it does not seem like there is enough staff to take care of the
resident's needs. It is worse mostly on weekends. Resident #66 was not interviewable as her BIMS was 04
(severe cognitive impairment).
h) On 09/23/24 at 2:47 PM, Resident #33, who has a BIMS score of 15, said the facility is short staffed. It
takes at least 45 minutes to answer the call light.
i) On 09/24/24 at 10:51 AM, Resident #4, who has a BIMS score of 15, stated, It takes over an hour, or
sometimes several hours, to answer the call light.
j) On 09/23/24 at 12:54 PM, Resident #395's family member voiced concern with lack of staff. She said, it
takes about 45 minutes for [Resident #395] to get changed, and at night she often hears other resident's
calling out for help.
k. On a follow up interview on 09/27/24 at 9:31 AM, Resident # 395's family member stated she left
[Resident 395's] curtain up at a specific height on purpose to see if staff would adjust it, but it was not
adjusted at all, and [Resident 395's] TV was left on all night.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 9 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview, the facility failed to ensure beverage of choice and timeliness of meals, as per
preference for 3 of 4 sampled residents (Residents #18, #31, and #143).
The findings included:
Review of the Meal Service of Operation schedule revealed breakfast for Wing #3 on the second floor was
scheduled for delivery between 8:15 AM and 8:30 AM daily. Residents #18, #31, and #143 resided on this
unit.
1) Review of the record revealed Resident #18 was admitted to the facility on [DATE].
Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had
a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was
cognitively intact.
Review of the current orders revealed Resident #18 was on a regular textured and thin liquid consistency
diet.
During an interview on 09/23/24 at 12:49 PM, Resident #18 reported that breakfast was consistently late,
being served to her between 9 AM and 10:30 AM, and that she could not get any coffee until the trays
arrived to the unit. Resident #18 stated, Yesterday they didn't even have any coffee. They offered me hot
chocolate.
During an observation and interview on 09/24/24 at 10:25 AM, the resident's finished breakfast tray was still
at the bedside. When asked what time she received her breakfast that morning, Resident #18 stated about
9:40 AM.
During an interview on 09/25/24 at 12:46 PM, Resident #18 stated she received breakfast about 10:30 AM
that morning. When told breakfast was delivered to the first floor about 8:30 AM that same morning, and
was she sure her breakfast was that late, Resident #18 stated she was sure, further adding, If I got my
breakfast at 8:30 AM I would pass out.
2) Review of the record revealed Resident #31 was admitted to the facility on [DATE].
Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15.
During an interview on 09/23/24 at 12:36 PM, Resident #31 stated, They can't get breakfast up here until 9
AM or 10 AM, and didn't get coffee for two days. When asked how he usually got coffee at the facility, the
resident stated it usually comes on the tray with his meal. Resident #31 again stated they did not have
coffee for two days and when he asked staff for it, they told him they didn't have any coffee.
3) Review of the record revealed Resident #143 was admitted to the facility on [DATE]. The record lacked a
completed MDS, as the resident had been recently admitted , but the nursing admission assessment
documented the resident was alert and oriented. Review of the Food Preferences form dated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 10 of 11
Printed: 05/28/2026
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
106091
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luxe at Wellington Rehabilitation Center The
10330 Nuvista Avenue
Wellington, FL 33414
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 0803
09/16/24 documented Resident #143 preferred coffee and milk for all three meals.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 09/24/24 at 11:10 AM, Resident #143 stated the meals were always late and there
was no coffee for two days. The resident stated in frustration, Breakfast at 11:30 AM is ridiculous. Resident
#143 further stated, Lunch at 3 PM and dinner at 7:30 PM is crazy. They need more people in the kitchen,
or they need to open up earlier. I want meals at a decent time.
Residents Affected - Few
During an observation and interview on 09/25/24 at 1:01 PM, Resident #143 again stated that food was
delivered late every day. The resident further stated, Look! What do I have to do to get whole milk? When
asked if she had spoken to anyone about the milk, Resident #143 stated she had and stated it was even
documented on her meal ticket. An observation of the resident's meal ticket documented, MILK WHOLE
and a pint carton of nonfat milk was observed on the tray. (Photographic Evidence Obtained).
During an observation on 09/27/24 at 1:11 PM, lunch had just been served to Resident #143. The meal
ticket documented MILK WHOLE. None of the other food preferences were documented in all capital
letters. A pint carton of nonfat milk was noted on the meal tray.
(Photographic Evidence Obtained).
During an interview on 09/27/24 at 1:20 PM, when asked the process for delivery of meals, the second floor
Unit Manager (UM) explained the process included checking the meal ticket with the delivered food to
ensure the correct meal was provided. When asked if they also check the beverages, the UM confirmed
they did. When told about the lack of whole milk for Resident #143 this week, the UM was unsure as to why
it happened. When asked if there had been a problem with not having coffee over the weekend or the
previous week, the UM stated she was not told of any issues over the weekend, and stated there was not a
problem last week.
During an interview on 09/27/24 at 1:33 PM, the Regional Food Service Manager stated coffee is always
available and was unaware of any recent issues. When told of the lack of whole milk for Resident #143 he
again was unsure as to why the resident was not provided her beverage of choice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
FAQ · About this visit
Common questions about this visit
What happened during the September 27, 2024 survey of LUXE AT WELLINGTON REHABILITATION CENTER THE?
This was a inspection survey of LUXE AT WELLINGTON REHABILITATION CENTER THE on September 27, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUXE AT WELLINGTON REHABILITATION CENTER THE on September 27, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.