Wellington Rehabilitation And Healthcare
Wellington Rehabilitation and Healthcare in Knightdale, NC — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included: Resident #17 was admitted to the facility on [DATE] with a diagnosis of quadriplegia and tracheostomy status. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.
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.
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