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
observation and interviews, the facility failed to provide residents with a dignified existence and
communication with staff in and outside of the facility for 3 of 4 sampled residents reviewed for resident
rights (Resident #6, #7 and #8).
The findings included:
1). In an observation conducted on 04/16/2025 at 2:00 PM on the second floor of the facility, the surveyor
noted that the nurses' station was empty. The surveyor walked around for 45 minutes and never saw a staff
member. There were 40 residents on this second floor unit.
2). In an interview conducted on 04/16/2025 at 2:35 PM Resident #6's wife stated that she can never get in
contact with the facility staff when she calls, she always must come to the facility if she has a question
which is never answered because it seems that no one ever has an answer. Resident # 6's wife further
stated that she doesn't see nurses nor CNA's (certified nursing assistants) around during her visits.
Record review revealed Resident #6 was admitted on [DATE] post CVA (cerebrovascular accident). His
Brief Interview of Mental Status (BIMS) score was 11 on the 5-day Minjimum Data Set (MDS) with an
Assessment Reference Date (ARD) of 04/01/25. This indicated mild cognitive impairment.
3). In an interview conducted on 04/16/2025 at 2:20 PM Resident # 7's wife stated that she would love to
see staff members come into her husband's room to care for him because she comes in the morning and
leaves in the afternoon and the only time that she sees a staff member is for med pass and at lunch. If they
need anything, no one is around to help them. She further revealed that her husband has been waiting to
see a speech therapist for days now. And that exactly today she got a call from her insurance company
saying that the doctor came to see her husband, but she spent the whole day with the husband and didn't
see any doctor come around. Resident # 7's wife also stated that it's pointless talking to the front desk
because their answer is always: I will investigate and get back to you which never happens.
Record review revealed Resident #7 was admitted on [DATE] post CVA. His BIMS score was 14 on the
admission MDS with an ARD of 04/13/25. This indicated intact cognition for this resident.
4). In an interview conducted on 04/16/2025 at 2:30 PM, Resident #8 stated angrily that she spent the
whole day trying to find social services from the facility phone with no success. Every time she calls the
front desk she gets transferred to Social Services and no answer. Resident # 8 stated that
(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 9
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
04/16/2025
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
this facility is very big and nice, but the staff members are not so nice.
Level of Harm - Minimal harm
or potential for actual harm
Record review revealed Resident #8 was admitted on [DATE] for aftercare following joint replacement
surgery. Her BIMS score on the 5-day MDS with an ARD of 04/14/25 was 15. This indicated the resident
had intact cognition.
Residents Affected - Few
On 04/16/25 at 3:20 PM, the Administrator was apprised of the interviews with the residents and
representatives and stated that she receives messages on her phone from residents, and families come
into her office all of the time to speak with her. During further interview, it was discussed regarding Resident
#8 not being able to reach the social worker today, she responded that the social worker is off today.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 2 of 9
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
04/16/2025
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 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record and policy review; the facility failed to protect a resident's right to be free
from neglect by failure of staff to respond timely to the resident's change of condition which resulted in
hospitalization for 1 of 2 residents sampled for change in condition (Resident #4).
The findings included:
The facility's policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of
Unknown Origin issued 08/2022 and revised 01/2024 revealed, Neglect occurs when the facility is aware of,
or should have been aware of, goods or services that a resident (s) requires but a facility fails to provide
them, to the resident (s), that has resulted in or may result in physical harm, pain, mental anguish, or
emotional distress.
Resident #4 was admitted to the facility on [DATE] post-acute care hospitalization. Diagnoses included
Dysarthria following Cerebral Infarction, Encounter for Surgical Aftercare Following Surgery on the
Circulatory System, Asthma, Heart Failure and Unspecified Atrial Fibrillation. On the Discharge Return
Anticipated Minimum Data Set with an assessment reference date of 04/05/25 her Brief Interview for
Mental Status was unable to be conducted which indicated she was severely cognitively impaired.
Review of the Electronic Health Record (EHR) for Resident # 4 revealed she was admitted to the facility in
the evening of 04/03/25.
On 04/04/25 at 7:03 AM a nursing skilled documentation note revealed Pt is alert and responsive, Skin
warm and dry. Breathing even and unlabored. All care provided by assigned staff; Turning and repositioning
done per facility protocol. Call light in reach; Bed in low position. Care continues.
On 04/04/25 skin/wound documentation revealed skin changes which were reported to the physician.
On 04/04/25 she was also seen by the Dietitian, the activities assistant and the Medical Director.
There was no documentation from the primary nurse on the first shift.
On 04/05/25 at 8:10 AM nursing documentation revealed, Patient remain stable, no acute respiratory
distress, no c/o pain or discomfort noted. Safety maintained, call light within reach. Plan of care continues.
A review of the Medication Administration Record (MAR) for April 2025 revealed, the resident took her
medications on 04/04/25 and at 6:00 AM on 04/05/25. The medications were marked as refused for the
9:00 AM medications.
On 04/05/25 at 9:20 AM, Staff H, a Licensed Practical Nurse (LPN), documented that the resident refused
her medications.
A record review of the Blood pressure (BP) for Resident #4 revealed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 3 of 9
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
04/16/2025
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 0600
4/5/2025 15:10
Level of Harm - Actual harm
(3:10pm) -158 / 69
Residents Affected - Few
4/5/2025 09:19
- 101 / 82
4/4/2025 23:52 (11:52pm)
121 / 63
4/4/2025 10:04
- 116 / 58
4/4/2025 07:06 - 123 / 81
4/3/2025 19:12
(7:12pm) -115 / 83
A record review of the Pulse readings for Resident #4 revealed:
4/5/2025 15:10
- 78 bpm
Regular
(beats per minute)
4/5/2025 09:19
- 111 bpm
Irregular - new onset
4/4/2025 23:52
- 61 bpm
Regular
4/4/2025 10:04
- 68 bpm
Regular
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 4 of 9
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
04/16/2025
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 0600
4/4/2025 07:06
Level of Harm - Actual harm
- 71 bpm
Residents Affected - Few
Regular
4/3/2025 19:13
- 68 bpm
Regular
The next entry into the nursing progress notes was on 04/05/25 at 2:45 PM which revealed, Resident
transferred to [Emergency Room] ER for evaluation and treatment. Resident observed by nurse at the
bedside nonresponsive verbally, but responsive to touch. Resident able to move all extremities [with] w/
weakness in left upper extremity from previous CVA. Resident vital signs were assessed BP 158/69,
HR-78, [Oxygen Saturation] O2-96, [Respirations] R-16, [Blood Sugar] BS-158. Resident unable to verbally
express if experiencing any pain. Resident assessed by Nurses X3, on shift supervisors X2 at the bedside.
P.A. was immediately notified of changes. Orders received to transfer resident out to [WRMC, a local
hospital] for evaluation and treatment.
A review of the facility's transfer form revealed, the resident had altered mental status, was not alert, and
was transferred to the hospital on [DATE] at 3:09 PM.
A telephone interview was conducted with Staff J, a Certified Nursing Assistant (CNA) on 04/16/25 at 2:10
PM. Staff J stated she was the primary CNA for Resident #4 on 04/05/25. Staff J stated the resident was
moving but not opening her eyes during her rounds between 7:30 AM-8:00 AM on 04/05/25. When
breakfast came, she set up her tray, called her name and she was moving but not opening her eyes. She
left the tray there and reported it to the nurse. She checked her brief which was dry, she did not give her
personal care or dress her because her eyes were closed the whole morning. When lunch came, she
brought her tray. She was still moving but not opening her eyes. She did not eat lunch. She did not drink
anything. The nurse called Staff D, a Physician Assistant, (PA) and another nurse tried to put in an IV
(intravenous line). The daughter came in and was upset and the resident was not alert. Paramedics came
and she went to the hospital.
A telephone interview was conducted with Staff D, PA, on 04/16/25 at 2:32 PM. She was asked if she was
notified that Resident #4 refused her morning medication. She stated she was notified around 2-2:15 PM
on 04/05/25 that she did not eat breakfast or lunch, so she assumed she did not take her medication. She
stated she was on call and not in the building to evaluate the resident.
An interview was conducted via telephone on 04/16/25 at 4:12 PM with Staff G, Registered Nurse (RN),
Unit Manager. Staff G stated that she worked that day and there was another manager there that she was
helping. She stated she was not aware at all that day that Resident #4 had not opened her eyes all day. She
was not aware that the resident did not eat breakfast or lunch. At about 3:02 PM, Staff J asked her to check
the resident, she was told a nurse was trying to start an IV on the resident. She stated she went into the
room and there was froth in the resident's mouth. She checked her pupils, and they were deviating to the
right. She thought she may have had another CVA (cerebral vascular accident/stroke). Just at that time, the
resident's daughters came into the room very upset. The paramedics came at the same time and asked the
primary nurse when the last time it was that she saw
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 5 of 9
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
04/16/2025
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 0600
the patient awake and she stated when she gave report to the night nurse yesterday.
Level of Harm - Actual harm
A telephone interview was conducted with Staff I, RN on 04/16/25 at 4:20 PM. Staff I stated she was asked
to put in an IV for Resident #4. She stated it was about 2:50 PM on 04/05/25. She entered the room and
looked at the resident. She was making a snoring sound. She did not respond to a sternal rub. Her pupils
were dilated but uneven. 911 was called and the daughter came.
Residents Affected - Few
A telephone interview was conducted with Staff H, LPN, on 04/16/25 at 4:31 PM. She stated she has been
working in this facility for a year. She stated she was the resident's nurse on 04/05/25. She also had her on
04/04/25 and on that day she was in the chair and using the white board to communicate. On 04/05/25 she
went into Resident 4's room with Staff J to say good morning and she moved her arms and legs. She did
not respond verbally. It appeared she was sleeping, snoring. She did her vitals, blood pressure and blood
sugar and she responded to pain. She assumed she was tired. Around 8:00 AM-9:00 AM she could not give
her meds. Then around 12:30 PM, Staff J noticed she did not eat lunch. She asked another LPN working on
another hallway to do an assessment on Resident #4. That nurse did an assessment and thought she was
really tired and weak but she was still moving her lips and arms and her blood sugar 188.
Staff H texted the PA at 12:30pm and said today she is not like herself and not as alert. The PA said to call
the family to start an IV, stat chest x-ray, labs, and urine analysis. When asked if she asked the Unit
Manager to check the resident, she stated that the Unit Manager was busy with another family at the time.
She got a message from the receptionist that the daughter called around 1:30 PM. She called the daughter
back about the change in condition and got the ok to start an IV. She asked Staff I to insert the IV. When
she laid the resident back, the pupil assessment was unusual, and she texted the PA at 2:45pm to ask to
send her to the hospital via 911.
The two supervisors came into the room, the family came, and the paramedics came. The paramedics
wanted to know when I saw her awake last, and I said she was sleeping this morning. They took her to the
hospital.
An interview was conducted with the Administrator on 04/16/25 at 3:24pm. The Administrator stated she
was aware of Resident #4's condition on 04/05/25 since the resident's daughter had spoken to her about it
on 04/07/25.
On 4/5/2025, the resident was admitted to the Intensive Care Unit with a diagnosis of a CVA
(Cerebrovascular Accident).
A review of the hospital records for Resident #4 was conducted. A review of the History and Physical
performed on Resident 4 on 04/05/25 at 5:33 PM, revealed the Glasgow Coma Scale results. The eye
opening response was to pain, best verbal response was incomprehensible sounds, best motor response
was flexes and withdraws to painful stimuli. The residents Glasgow Coma Score was 8.
The Glasgow Coma Scale (GCS) is a system to score or measure how conscious you are. The highest
possible GCS score is 15, and the lowest is 3. A score of 15 means you're fully awake, responsive and
have no problems with thinking ability or memory. Generally, having a score of 8 or fewer means you're in a
coma. The lower the score, the deeper the coma is.
Facility staff did not recognize a decline in Resident #4's condition on 4/5/25 until approximately 12:30 PM
on 4/5/25 and Resident #4 was transferred to the hospital at 3:09 PM.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 6 of 9
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
04/16/2025
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 - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and interviews, the facility failed to ensure residents receive treatment and care in
accordance with professional standards by failing to recognize one out of 2 residents sampled (Resident
#5), after admission to the nursing home was not on medication for a diagnosis of Atrial Fibrillation. The
resident was readmitted to the hospital with a diagnosis of Bilateral Pulmonary Embolism.
Residents Affected - Few
The findings included:
Resident #5 was admitted to the facility post-acute care hospitalization on 03/07/25. Her admitting
diagnoses included Staphylococcal Arthritis of Left Knee, Cellulitis of Left Lower Limb and Unspecified
Atrial Fibrillation. Her Brief Interview for Mental Status was 15 on the 5-day Minimum Data Set with an
assessment reference date of 03/12/25. This revealed the resident had intact cognition.
A review of the Electronic Health Record (EHR) revealed the resident was evaluated by a nurse practitioner
(NP) on 03/07/25. The NP note revealed was found with new onset of afib/aflutter- started on Eliquis. Pt
stabilized and transferred to Luxe. Atrial fibrillation (Afib) is an irregular and often rapid heart rhythm that
can lead to various complications, including blood clots, stroke, and heart failure.
(Atrial flutter is an abnormal heart rhythm in the heart's upper chambers (atria). The atria beats too fast.
This may cause dizziness and fatigue.)
A review of the Eliquis prescriber information revealed Eliquis is an oral anticoagulant used to prevent and
treat blood clots. Eliquis is used to lower the risk of stroke or a blood clot in people with atrial fibrillation.
Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic
events. If anticoagulation with ELIQUIS is discontinued for a reason other than pathological bleeding or
completion of a course of therapy, consider coverage with another anticoagulant.
On 03/09/25 the resident was seen by the same NP who wrote a progress note revealing the resident Was
found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. In that same
note the NP wrote Hospital/old records reviewed and new onset afib- on Eliquis.
On 03/10/25 the pharmacist wrote a note revealing Medication Regimen reviewed: No recommendation
made.
On 03/11/25 a review of a physician note revealed Was found with new onset of afib/aflutter- started on
Eliquis. The note continued to reveal I personally reviewed records including acute care hospital, skilled
nursing facility, and therapy records. Summarization of the acute care course can be found in the HPI
section. Discussed case with the primary medical team and/or leadership.
On 03/11/25, the Medical Director wrote a progress note in the EHR revealing was found with new onset of
afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. Hospital/old records reviewed, new
onset afib- on Eliquis, dvt proph: Eliquis. (DVT is deep vein thrombosis and proph is prophylactic which
indicates a drug used to prevent deep vein blood clots.)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 7 of 9
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
04/16/2025
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
Level of Harm - Actual harm
On 03/13/25 Staff D, a Physician Assistant (PA) wrote a progress note that revealed was found with new
onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. Hospital/old records reviewed,
new onset afib- on Eliquis, dvt proph: Eliquis.
Residents Affected - Few
On 03/14/25, the physician who wrote a note on 03/11/25 wrote another note revealing was found with
new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe.
On 03/14/25 an APRN (Advanced Practice Registered Nurse) wrote a progress note that revealed was
found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe.
On 03/15/25 a record review of Occupational Therapy (OT) notes revealed Patient reports feeling dizzy
upon sitting EOB (edge of bed), before therapist could assist pt (patient) back to bed, pt passed out and
was unresponsive x 30 sec (seconds). Pt regained consciousness, however diaphoretic and c/o
(complained of) dizziness and possible passing out again. Pt's BP (blood pressure) =121/107. Pt's O2
(oxygen saturation) at 83 on room air. Pt placed on 2.5 liter O2 (oxygen) via face mask, after approximately
5 minutes, pt's O2 increased to 97%. Pt provided with cold was cloth. Nsg (nursing) staff assisted with pt
and soon after pt was transported to hospital.
A review of the March 2025 Medication Administration Record (MAR) indicated that the resident never
received Eliquis while at the nursing home. A review of Physician orders revealed the resident never had an
order for Eliquis at the nursing home.
A review of the resident's care plan dated 03/10/25 revealed, The resident has altered cardiovascular status
related to Hypertension, Hyperlipidemia and A-fib.
Review of Resident #5's hospital records prior to admission to the nursing home which were included in the
EHR revealed:
Per hospital record documented on 03/05/25 - Cleared from cardiac standpoint. Stop heparin, restart
Eliquis.
Review of hospital records revealed AF/Flutter. New onset, was not in AF when she came in. TEE
(transesophageal echocardiography which can detect blood clots in the heart) done no [NAME] (left atrial
appendage which is a small sac in the muscle wall of the left atrium where blood could collect and form
clots with someone with atrial fibrillation) clot. Cardioverted her during TEE but went back into rate
controlled
AF/ Flutter In and out of atrial flutter. Rate controlled. EF normal.
Metoprolol
Eliquis
TELE [Telemetry] : Atrial flutter
Cleared for discharge
FU [follow up] in office 2-3 weeks for [Paroxysmal Atrial Fibrillation] PAF/Atrial flutter
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
Page 8 of 9
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
04/16/2025
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
Level of Harm - Actual harm
Residents Affected - Few
The physician note revealed a cardioversion (a procedure that uses electrical shock to restore an irregular
heartbeat to a normal rhythm) was done in the hospital prior to discharge. This was done during a TEE. The
TEE revealed no [NAME] clot.
EF (ejection fraction is a percentage of how much blood the ventricles pump out with each heart
contraction). TELE (telemetry which monitors heart rate and rhythm).
A telephone interview was conducted with Staff D, Physician Assistant (PA) on 04/16/25 at 2:32 PM. She
was asked why her note, and every Physician and NP note revealed the resident was on Eliquis. She stated
that it should have been picked up that the resident was not on Eliquis. It was not on the medication
discharge list, and it should have been questioned. She probably wrote her note based on the previous
notes.
A review was done of the Hospital emergency room record from 03/15/25 and hospital records from the
admission on [DATE] to discharge on [DATE] revealed, the resident was admitted to the hospital with a
diagnosis of Bilateral Pulmonary Embolism. An Inairi pulmonary thrombectomy was performed on 03/18/25.
A bilateral pulmonary embolism is a clot in the veins of both lungs that occurs when a blood clot that has
arisen from a different area obstructs the pulmonary arteries.
Mechanical thrombectomy, or simply thrombectomy, is the removal of a blood clot (thrombus) from a blood
vessel.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106091
If continuation sheet
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