Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellington Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A Unit Manager did not follow infection control protocols during tracheostomy care for a resident with quadriplegia, failing to change gloves and perform hand hygiene between handling soiled and clean materials. This lapse was observed and confirmed through staff interviews, revealing a lack of awareness of proper procedures to prevent contamination.
A dependent resident with severe physical limitations did not have her call light device consistently placed within reach, despite staff training and care plan requirements. Staff were observed leaving the room without ensuring the call bell was accessible, and the resident reported this occurred frequently, leaving her unable to request assistance as needed. The issue was only corrected when a therapist noticed and repositioned the call bell appropriately.
Surveyors identified that several residents' MDS assessments were inaccurately coded regarding PASARR status, antiplatelet medication administration, and falls. For example, a resident with a Level II PASARR determination was not coded as such, another receiving daily Aspirin was not marked as receiving antiplatelet therapy, and a resident's fall with injury was omitted from the discharge MDS. Staff interviews confirmed these errors were due to oversight and inaccurate documentation.
A resident with bipolar affective disorder was admitted with a PASRR Level II approval limited to a 30-day stay, but the facility failed to recognize and act on the expiration of this approval. The PASRR letter was not scanned into the electronic record, leading to a missed rescreening. The oversight was discovered during an audit, and the resident reported no concerns with care at the time.
The facility did not include required PASRR Level II status in the care plans of two residents and failed to add hospice care services to the care plan of another resident. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating care plans to reflect these critical services.
Three residents' care plans were not properly updated: one resident's code status was incorrectly listed as DNR instead of full code, another resident's care plan did not include a new stage 3 pressure ulcer despite physician orders, and a third resident's care plan continued to reference bed rails after they had been removed due to cognitive changes. Staff interviews revealed confusion about responsibility for updating care plans.
A resident with a physician's order for daily lidocaine patches had the patches applied as directed, but nursing staff failed to consistently remove them according to the schedule. Instead, the resident was allowed to remove the patches herself, and staff did not verify removal, resulting in patches remaining on beyond the prescribed time. Interviews with nursing staff and leadership confirmed that the patches were not removed as ordered.
A resident with a hand contracture had a resting hand splint applied by nursing staff without a physician's order, therapy instructions, or a documented wearing schedule. The splint was present in the resident's room and was applied based on staff assumptions rather than formal guidance, despite the resident not being cleared by therapy to use the splint outside of supervised sessions. The application and removal of the splint were not documented in the medical record or TAR, and the resident was unaware of its intended use.
A resident with Parkinson's disease was found with bilateral quarter length side rails in use without documented assessment, entrapment risk evaluation, informed consent, physician's order, or care plan update. Staff interviews revealed confusion over responsibility for side rail assessments, and neither therapy nor nursing completed the necessary steps prior to installation.
A Business Office Manager failed to perform hand hygiene after moving a urinal and before assisting a resident with their meal, including opening a milk carton and placing a straw, contrary to facility policy. The staff member had received infection control training but did not follow proper procedures during the observed event.
A resident with a seizure disorder did not receive his prescribed Keppra medication after returning from the hospital due to a transcription error. The nurse responsible failed to have another nurse verify the medication orders, resulting in four missed doses and subsequent seizures that required hospitalization.
A resident with cognitive impairment and mobility issues was found with long fingernails, despite care plans requiring regular trimming. Staff interviews revealed that the resident did not refuse care, but the nurse aide failed to notice the nail length. The DON confirmed that nails should be trimmed on shower days or when noticed, but this was not done.
A facility failed to follow infection control protocols during tracheostomy and pressure ulcer care. A Respiratory Therapist did not perform hand hygiene or wear a gown while caring for a resident on enhanced barrier precautions. Additionally, a Treatment Nurse did not perform hand hygiene between glove changes during pressure ulcer care. Both staff members were unaware or forgot the facility's policies, leading to potential infection risks.
A resident with Alzheimer's and blindness was using bolsters to prevent falls, brought in by their responsible party. The facility failed to assess these bolsters as restraints, lacked medical justification, and did not have a physician order. Staff were aware of the bolsters but did not remove them, and there was no consensus on whether they were restraints. The Administrator acknowledged the need for an assessment, leading to a deficiency.
The facility failed to complete significant change MDS assessments for two residents following changes in their hospice care status. One resident was admitted to hospice without the required assessment, and another was discharged from hospice without the assessment being completed within 14 days. Staff interviews confirmed the necessity of these assessments, but they were missed.
A facility failed to accurately code the MDS assessment for a resident regarding antianxiety medication. Despite an indication of medication use, records showed no administration of clonazepam or other antianxiety drugs. The MDS Nurse admitted to an error in coding, and the DON emphasized the need for accurate assessments.
A medication cart was left unattended and unlocked in a hallway between rooms 143-150. The cart was visible from the nurse's station, but no staff were present. Medication Aide returned to the cart and confirmed it was left unlocked. Interviews with the DON and Administrator confirmed the cart should be locked when not in use.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
Unit Manager #2 failed to adhere to professional standards of practice and infection prevention protocols during tracheostomy care for a resident with quadriplegia and a tracheostomy. During a continuous observation, the Unit Manager removed soiled split gauze and a soiled inner cannula from the resident's tracheostomy site, disposed of them, and then proceeded to handle clean supplies and perform subsequent tasks without changing gloves and performing hand hygiene between the soiled and clean portions of the procedure. The Unit Manager only removed gloves and performed hand hygiene after completing the entire care process, including handling both soiled and clean items. Interviews with the Unit Manager revealed a lack of awareness regarding the need to change gloves and perform hand hygiene between handling soiled and clean materials during tracheostomy care. The Infection Preventionist and Administrator both confirmed that the expected standard of care would require splitting the procedure into soiled and clean parts, with appropriate glove changes and hand hygiene to prevent the spread of disease-causing organisms to the resident's airway. The failure to follow these protocols was directly observed and confirmed through staff interviews.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure a dependent resident's call light device was consistently placed within reach, as required by the resident's care plan. The resident, who had multiple sclerosis and post-polio syndrome, was dependent on staff for all activities of daily living and could only use the call bell if it was positioned directly under the side of her neck due to limited muscle control. During observations, the call bell was found clipped to the resident's upper right chest, which she stated was not accessible, and later was observed lying on the floor out of reach. The resident reported that staff often left the room without ensuring the call bell was correctly positioned, making her feel helpless. Multiple staff interviews confirmed that both nursing and therapy staff were trained to ensure call bells were within reach before leaving a resident's room, but this was not consistently practiced. On one occasion, a nurse entered the room, performed care tasks, and left without checking the call bell's placement. The assigned nursing assistant also left the resident without the call bell in reach, planning to return shortly but did not immediately do so. The speech therapist ultimately noticed the call bell was out of reach and repositioned it appropriately. Facility leadership, including the unit manager, DON, and administrator, all stated that call bells should always be within reach, regardless of the resident's ability to call out for help.
Inaccurate MDS Coding for PASARR Status, Medication, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of Pre-admission Screening and Resident Review (PASARR) status, medication administration, and falls. For one resident with a history of cerebral infarction, the MDS assessment did not reflect her current Level II PASARR determination, despite documentation and staff acknowledgment that she had an active Level II PASARR status. Another resident with a history of cerebrovascular accident was not coded as receiving antiplatelet medication on the MDS, even though physician orders and medication administration records confirmed daily administration of Aspirin, an antiplatelet agent. Staff interviews confirmed these coding errors were due to oversight. A third resident, admitted with a progressive neurological condition, was also incorrectly coded on the MDS as not having a Level II PASARR determination, despite documentation to the contrary. Additionally, this resident experienced a fall resulting in a laceration and hospital visit, but the incident was not captured in the discharge MDS assessment. Staff interviews revealed that the fall should have been documented in the MDS, but was missed. In each case, staff and administration acknowledged that the MDS assessments were not coded accurately, as required.
Failure to Timely Rescreen Expired PASRR Level II for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to obtain further approval and screening through the Level II Pre-admission Screening and Resident Review (PASRR) evaluation process as required for a resident with a diagnosis of bipolar affective disorder. The resident was admitted with a PASRR Level II Determination Notice that specified nursing facility placement was appropriate for a limited stay of no more than thirty days, with an explicit expiration date. However, the facility did not recognize that the PASRR had expired, and the required rescreening was not completed in a timely manner. The deficiency was identified when the Social Worker discovered the expired PASRR during a periodic audit, noting that the original PASRR letter had not been scanned into the electronic record, which contributed to the oversight. Interviews confirmed that the facility had not been consistently tracking PASRR statuses to ensure they were current, and the lapse was only discovered after the expiration had already occurred. The resident involved reported receiving all needed care and had no concerns at the time of the survey.
Failure to Develop Comprehensive Care Plans for PASRR and Hospice Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all required areas for three residents. For two residents with Level II Pre-admission Screening Resident Review (PASRR) determinations, their care plans did not reflect their PASRR status in a timely manner. One resident's PASRR Level II status was not included in the care plan until several months after admission, despite documentation and staff interviews confirming the requirement. There was confusion among staff regarding responsibility for ensuring PASRR status was included in the care plan, with both the Social Worker and MDS Nurses indicating differing understandings of their roles. Another resident's Level II PASRR determination was not care planned due to the notification letter not being uploaded into the system, which staff acknowledged as the likely cause for the omission. Additionally, a resident who was accepted into hospice care did not have hospice services reflected in their care plan, even though hospice provider notes and the Minimum Data Set indicated the resident was receiving hospice care. Staff interviews confirmed that hospice care should have been included in the care plan, and the MDS Nurse responsible acknowledged the omission. The Director of Nursing and Administrator both stated their expectation that hospice care would be included in the care plan when initiated.
Failure to Revise Care Plans for Code Status, Pressure Ulcer, and Bed Rail Discontinuation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were accurately revised and updated for three residents, as required. For one resident with end stage renal disease on hemodialysis, the care plan incorrectly listed the code status as Do Not Resuscitate (DNR), despite both the physician's order and the advance directive indicating the resident was a full code. Multiple staff interviews revealed confusion regarding responsibility for updating the code status in the care plan, with MDS Nurses, the Social Worker, and the Administrator each providing differing accounts of who should make these updates. Another resident, who was readmitted with a stage 4 pressure ulcer of the sacrum, had a care plan that failed to include a newly developed stage 3 pressure ulcer on the right buttocks, despite a physician's order for wound care to that area. Staff interviews confirmed that the new wound should have been added to the care plan, and that MDS Nurses were responsible for making this update after being informed of new wounds during morning meetings. However, the stage 3 pressure ulcer was not incorporated into the care plan. A third resident, admitted with a history of stroke, had a care plan that continued to reference the use of bed rails even after the rails had been removed due to changes in the resident's cognition and safety needs. Observations and staff interviews confirmed that bed rails were no longer present or in use, and that the decision to remove them had been communicated in a morning meeting attended by the interdisciplinary team, including MDS Nurses. Despite this, the care plan was not updated to reflect the discontinuation of bed rails.
Failure to Remove Topical Pain Patch per Physician's Order
Penalty
Summary
A deficiency occurred when nursing staff failed to remove a topical lidocaine pain patch from a resident in accordance with the physician's order. The resident, who was alert and oriented, had a physician's order for lidocaine 4% patches to be applied to the shoulders and chest once daily and removed per schedule, with no order for self-administration. Observations revealed that the resident had three lidocaine patches on her body, dated from the previous day, and she reported that while the nurse applied the patches in the morning, she removed them herself whenever she chose. Documentation showed that the patches were applied as ordered, but removal was not consistently performed by nursing staff as required. Nurse interviews confirmed that on at least one occasion, a nurse allowed the resident to remove the patches herself and did not verify their removal. Another nurse observed that patches from the previous day were still present when applying new ones but did not notify the unit manager on that day. The unit manager did not recall being notified about the issue, and the DON stated that the nurse should have removed the patches herself according to the physician's order. The NP confirmed that the order specified a removal time for a reason and that the nurse should have followed the order.
Splint Applied Without Physician Order or Schedule
Penalty
Summary
A deficiency occurred when a resident with a right-hand contracture was found to have a resting hand splint applied without a physician's order, therapy instructions, or a documented splint wearing schedule. The resident was moderately cognitively impaired and had functional limitations in both upper and lower extremities. Although the resident had received occupational therapy for two days and was not enrolled in a restorative nursing program, there was no documentation in the medical record or Treatment Administration Record (TAR) regarding the application or removal of a splint. Observations revealed the splint was present in the resident's room on multiple occasions, and interviews with nursing staff indicated that the splint was being applied based on assumptions rather than formal instructions. Nursing staff reported reapplying the splint during their shifts, but acknowledged there was no physician's order or splint schedule, and the application was not documented as a task in the computer system. The resident herself was unaware of the purpose of the splint or when it should be worn. The Therapy Director clarified that the splint had been ordered for use only during supervised therapy sessions, as the resident was not yet able to tolerate it for extended periods. The plan was to provide a physician's order, staff training, and a splint schedule only after the resident could tolerate the splint for more than one hour. Despite this, the splint remained in the resident's room, leading to confusion among nursing staff and resulting in its unsupervised application.
Failure to Complete Required Assessments and Documentation Prior to Side Rail Installation
Penalty
Summary
The facility failed to follow required procedures before installing side rails for a resident diagnosed with Parkinson's disease. The resident was observed on multiple occasions with bilateral quarter length side rails in the raised position, yet there was no documentation of an assessment for side rail use, no evaluation of entrapment risk, no signed informed consent, no physician's order, and no care plan addressing side rail usage. The resident's medical record and care plan did not reflect the presence or use of side rails, and the quarterly MDS assessment indicated the resident did not have side rails as a restraint and was independent with bed mobility. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for side rail assessments. The Unit Manager stated she had never completed a nursing side rail assessment, while the ADON indicated that therapy should evaluate residents first, followed by a nursing assessment, consent, physician's order, and care plan update. However, neither therapy nor nursing staff had completed these steps for the resident in question. The Director of Therapy and Physical Therapist both stated they did not perform side rail assessments, and the Administrator was unable to explain why the required assessments and documentation were not completed for this resident.
Failure to Perform Hand Hygiene After Handling Urinal During Meal Assistance
Penalty
Summary
A deficiency occurred when the Business Office Manager failed to follow the facility's hand hygiene policy while assisting a resident with their meal. The Business Office Manager entered a resident's room to deliver a lunch tray, placing it on the overbed table next to a urinal containing urine. After obtaining the resident's permission, the Business Office Manager moved the urinal to the bedside table without donning gloves or performing hand hygiene. Subsequently, the Business Office Manager assisted the resident by removing the lid from the lunch plate, opening a milk carton, and placing a straw in the milk, all without performing hand hygiene after handling the urinal. Interviews with the Business Office Manager revealed a lack of awareness regarding the infection control implications of touching the urinal and then handling food items. The Infection Preventionist, DON, and Administrator all confirmed that the correct procedure would have involved setting the tray on a clean surface, donning gloves to move the urinal, removing gloves, and performing hand hygiene before assisting with the meal. Documentation showed that the Business Office Manager had received training on infection control and hand hygiene upon hire, but failed to implement these practices during the observed incident.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to administer seizure medication to a resident after he returned from the hospital, resulting in four missed doses of Keppra, an anti-seizure medication. The resident, who had a history of seizures related to a stroke, was admitted to the facility with a physician's order for Keppra 500 mg twice daily. However, upon his return from the hospital, the medication order was not entered into his electronic medical record, leading to missed doses on subsequent days. The resident experienced seizures on the third day after his return, which required readmission to the hospital. The seizures were attributed to the missed doses of Keppra, as the resident was sensitive to low levels of the medication. The oversight occurred because the nurse responsible for entering the medication orders did not have a second nurse verify the orders against the hospital discharge summary, as was the facility's protocol. Interviews with facility staff, including the Unit Manager and the nurse involved, revealed that the error was due to a failure in the transcription process. The nurse admitted to not having another nurse verify the medication orders, which led to the omission of the Keppra order. The facility's Consultant Pharmacist confirmed that the missed doses likely caused the resident's seizure activity.
Removal Plan
- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.
- Address how the facility will identify other residents having the potential to be affected by the same deficient practice.
- Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.
- Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to maintain proper personal hygiene for a resident who required assistance with activities of daily living. Resident #4, who was moderately cognitively impaired and had diagnoses including muscle weakness and lack of coordination, was observed with long fingernails on two separate occasions. The resident's care plan specified that his nails should be checked and trimmed on bath days and as necessary, yet this was not adhered to. Interviews with staff revealed that the resident did not refuse care, and the nurse aide responsible for his morning care admitted to not noticing the length of the resident's nails. The Director of Nursing confirmed that nails should be trimmed on shower days or when staff noticed they were long. Despite these protocols, the staff failed to notice and address the resident's long nails, leading to the deficiency.
Infection Control Lapses in Tracheostomy and Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy and enhanced barrier precautions during tracheostomy care for a resident. The Respiratory Therapist (RT) did not perform hand hygiene after touching a potentially contaminated surface and before handling the tracheostomy. Additionally, the RT did not wear a gown while providing care to a resident on enhanced barrier precautions, despite a sign on the door indicating the requirement. The RT was unaware of the facility's policy and mistakenly believed that tracheostomy care was not a sterile procedure. The RT's supervisor confirmed that the RT should have worn a gown and performed hand hygiene as per the facility's policy. In another instance, the facility failed to implement its hand hygiene policy during pressure ulcer care for a resident. The Treatment Nurse did not perform hand hygiene between removing soiled gloves and applying clean gloves while changing a dressing on a resident's pressure ulcer. The nurse admitted to forgetting to perform hand hygiene due to nervousness, although she acknowledged the importance of doing so to prevent infection spread. The Director of Nursing (DON) confirmed that hand hygiene should always be performed after removing soiled gloves and before applying clean ones. These deficiencies highlight lapses in following established infection prevention protocols, specifically regarding hand hygiene and the use of personal protective equipment. The RT and Treatment Nurse both failed to adhere to the facility's policies, which are designed to prevent the spread of infection and protect residents from potential harm.
Failure to Assess Bolsters as Restraints for Resident
Penalty
Summary
The facility failed to identify and assess bolsters as a restraint for a resident with Alzheimer's disease and blindness, who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's responsible party (RP) had brought in bolster pillows to prevent the resident from falling out of bed, as the resident could move around independently. However, there was no medical justification or physician order for the use of these bolsters, and no restraint assessment was completed. Observations revealed the bolsters were placed under the fitted sheet on either side of the resident, and staff were aware of their presence but did not remove them. Interviews with staff, including a nurse, nurse aide, Director of Rehabilitation, MDS Nurse, Director of Nursing, and the Administrator, revealed a lack of consensus on whether the bolsters constituted a restraint. The MDS Nurse indicated that bolsters under the fitted sheet would likely be considered a restraint, while the Director of Nursing and a nurse believed they did not restrict the resident's movement. The Administrator acknowledged the bolsters likely restricted movement, given the resident's condition, and stated the resident should have been assessed for their safe use. The facility's failure to properly assess and document the use of bolsters as a restraint led to this deficiency.
Failure to Complete Significant Change MDS Assessments for Hospice Status Changes
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for two residents following changes in their hospice care status. Resident #76, who had chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's disease, was admitted to hospice care, but the required MDS assessment was not completed. Interviews with the Director of MDS Education and the MDS Nurse confirmed that the assessment was necessary following the hospice election, but it was missed. The Director of Nursing also acknowledged that MDS assessments should be completed according to the Resident Assessment Instrument (RAI) manual's schedule. Similarly, Resident #48, who was initially admitted with hospice services, was discharged from hospice care, but the significant change MDS assessment was not completed within the required 14 days. The MDS Nurse was aware of the discharge but could not explain why the assessment was missed. The Director of Nursing and the Administrator were both unaware that the assessment had not been completed, although they confirmed it should have been done within the specified timeframe.
Inaccurate MDS Coding for Antianxiety Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of medications, specifically for unnecessary medications. The resident, who was admitted with a diagnosis of dementia, was noted to be moderately cognitively impaired and was indicated to be taking antianxiety medication. However, a review of the resident's physician orders and Medication Administration Record (MAR) revealed no documentation of the administration of clonazepam or any other antianxiety medication during the specified period. An interview with the MDS Nurse confirmed that the medication section of the resident's MDS assessment was coded in error, acknowledging it as a mistake. The Director of Nursing also indicated that the MDS assessments should be accurate.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart, which was observed between rooms 143-150. During a continuous observation, the medication cart was left unlocked from 8:35 AM to 8:47 AM, with the red dot on the push lock visible, indicating it was not engaged. The cart was parked in the hallway, visible from the nurse's station, but no staff were present. Two Nurse Aides were passing breakfast trays, and no residents were near the cart. Medication Aide #1 returned to the cart at 8:47 AM and opened the top drawer without unlocking it, confirming she had left it unlocked. Interviews with the Medication Aide, the Director of Nursing, and the Administrator confirmed that the cart should be locked when not in use, and the Medication Aide was responsible for it during their shift.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Knightdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capital Nursing And Rehabilitation Center | 5.6 mi | ★★★★★ | 6 | 0 |
| Tower Nursing And Rehabilitation Center | 5.6 mi | ★★★★★ | 2 | 0 |
| Sunnybrook Rehabilitation Center | 5.8 mi | ★★★★★ | 7 | 1 |
| Perry Creek Health And Rehabilitation Center | 8.1 mi | ★★★★★ | 12 | 0 |
| The Cardinal At North Hills | 9.1 mi | ★★★★★ | 2 | 0 |
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