Wellington Rehabilitation And Healthcare
Inspection Findings
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and staff interviews the facility failed to follow professional standards of practice and infection prevention measures when Unit Manager #2 (UM #2) failed to remove soiled gloves, perform hand hygiene and don clean gloves during tracheostomy (a surgical procedure that creates an opening in
the trachea (windpipe) through the front of the neck to create an artificial airway and assist with breathing) care for 1 of 1 residents reviewed for tracheostomy care (Resident #17). Findings included: Resident #17 was admitted to the facility on [DATE REDACTED] with a diagnosis of quadriplegia and tracheostomy status. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed he was cognitively intact.
Resident #17 was coded in the MDS as receiving tracheostomy care in the facility. Resident #17's care plan with a revision date of 6/22/25 revealed him to have a tracheostomy. A continuous observation of tracheostomy care was conducted on 10/2/25 starting at 8:14 AM. Unit Manager #2 (UM #2) entered the resident's room, performed hand hygiene and donned a gown and gloves. UM#2 then removed the soiled split gauze from behind the tracheostomy flange and threw it in the trash. UM#2 then opened the clean split gauze and placed it behind the tracheostomy flange. At 8:18 AM, UM#2 removed the soiled inner cannula and threw it away. She proceeded to open the new sterile inner cannula and insert it into the tracheostomy.
UM #2 then removed the soiled gloves, performed hand hygiene, removed her gown, put it into the trash, removed the trash bag, tied it closed and removed it from the room. UM #2 proceeded to take the trash bag and dispose of it. In an interview with UM #2 on 10/2/25 at 8:27 AM, she indicated she thought she was performing tracheostomy care correctly. UM #2 was unaware she should have changed gloves and performed hand hygiene between soiled and clean parts of the procedure. In an interview with the Infection Preventionist (IP) on 10/2/25 at 8:45 AM The IP indicated she would expect Nurses to think critically about
the procedures they were performing. In this case, UM #2 should have considered the possibility of spreading disease causing organisms to the resident's airway by not removing soiled gloves after handling
the soiled split gauze and soiled inner cannula, performing hand hygiene and donning new gloves to place
the clean split gauze and clean inner cannula. The Administrator was interviewed on 10/2/25 at 9:01 AM.
The Administrator stated to decrease the risk of spreading disease causing organisms to the residents' airway, UM #2 should have split tracheostomy care into clean and soiled parts. She further stated UM #2 should have donned clean gloves, removed the soiled split gauze and soiled inner cannula, removed the soiled gloves, performed hand hygiene, donned clean gloves and placed the clean split gauze and clean inner cannula.
Residents Affected - Few
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
Event ID:
Wellington Rehabilitation and Healthcare in Knightdale, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Knightdale, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Wellington Rehabilitation and Healthcare or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.