Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wilson Care And Rehab during CMS and state inspections, most recent first.
Nursing staff did not consistently use required Enhanced Barrier Precautions or perform proper hand hygiene during direct care of two residents, including wound care and catheter management. In both cases, staff failed to don gowns and, in one instance, placed a catheter drainage bag on the floor, contrary to facility infection control policies.
Residents repeatedly reported long call light response times, incomplete care, and negative staff attitudes, including staff turning off call lights without providing assistance and being loud during activities. Despite ongoing complaints documented in Resident Council meetings and staff being re-educated, the same issues persisted, with residents continuing to feel neglected and disrespected.
The facility did not provide fully completed Medicare Advanced Beneficiary Notice (ABN) forms to three residents when skilled services ended, omitting the required estimated cost of services. This left residents without full information about their potential financial liability for non-covered services, as confirmed by administrative staff and facility policy.
A consultant pharmacist did not identify or report the lack of required blood pressure or pulse monitoring before administration of a beta blocker for a resident with multiple health conditions. Additionally, the facility did not implement the pharmacist's recommendation for specifying the dosage of Voltaren gel, resulting in incomplete medication orders. Staff interviews revealed uncertainty about monitoring requirements and the need for clear dosage instructions.
A resident with multiple complex conditions did not have blood pressure or pulse monitored prior to receiving a beta blocker, and physician orders for topical Voltaren gel lacked clear dosage instructions for some applications. Staff interviews confirmed uncertainty about monitoring requirements and acknowledged that medication orders should specify dosages, as required by facility policy.
A resident's injectable medications were found to be expired during a medication cart inspection. Both an LPN and an administrative nurse confirmed that the Lispro pens had been in use beyond their 30-day expiration period and should have been discarded, in accordance with facility policy.
A resident with multiple chronic conditions receiving hospice care did not have a care plan that included essential information such as the hospice provider's contact details, the specific services and supplies to be provided, or the schedule of hospice staff visits. Staff interviews revealed a lack of clear communication and documentation regarding hospice coordination, contrary to facility policy requiring a coordinated care plan.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Nursing staff failed to follow required Enhanced Barrier Precautions (EBP) and hand hygiene protocols during direct care of residents under infection control interventions. In one instance, a licensed nurse prepared wound care supplies for a resident with a pressure ulcer and entered the resident's room without donning a gown as required by EBP status. The nurse also failed to perform hand hygiene before donning gloves, between glove changes, and after completing the wound dressing change. Supplies were placed directly on the resident's bedside table, and the nurse exited the room without washing or sanitizing hands. The nurse later acknowledged not realizing the omission of the gown or hand hygiene steps during the procedure. In another instance, a certified nurse aide entered a resident's room to empty a catheter drainage bag but did not don a gown as required by EBP. The aide placed the catheter drainage bag directly on the floor while obtaining a privacy bag, contrary to facility policy that requires keeping the drainage bag off the floor. Both administrative nurses confirmed that staff are expected to use gowns and gloves during such care and that the drainage bag should not be placed on the floor. Facility policies on infection prevention and indwelling urinary catheters specify the use of standard and transmission-based precautions, including proper hand hygiene and environmental practices.
Failure to Resolve Recurring Resident Council Concerns on Call Light Response and Staff Attitude
Penalty
Summary
The facility failed to resolve recurring issues reported by the Resident Council regarding call light response times and delivery of care. Over the course of nearly a year, Resident Council meeting minutes repeatedly documented concerns that staff were turning off call lights without completing requested care, not returning to assist residents, and displaying negative attitudes such as huffing, scoffing, and cussing when residents requested assistance. Residents also reported that staff were loud during activities like church and movies, and that staff frequently complained about being short-staffed or about coworkers in the presence of residents. These concerns were consistently raised in multiple council meetings, indicating a pattern of unresolved issues. Despite the facility's stated responses, such as providing staff re-education and discussing concerns at staff meetings, the same issues persisted in subsequent Resident Council meetings. Residents continued to report long wait times for call light responses and feeling like a burden to staff. Observations and interviews confirmed that these problems were ongoing, with residents expressing dissatisfaction with staff attitudes and the timeliness of care. The facility's policy required a designated staff member to respond to council concerns and for the Quality Assurance Committee to review council data, but the recurring nature of the complaints suggests these processes were not effective in resolving the deficiencies.
Failure to Provide Complete Medicare ABN Forms with Cost Estimates
Penalty
Summary
The facility failed to provide fully completed Advanced Beneficiary Notice (ABN) CMS Form 10055 to residents or their representatives when skilled services ended. Specifically, for three residents reviewed for Medicare Liability Notices, the ABN forms given did not include the required estimated cost of continued services. The ABN is intended to inform beneficiaries that Medicare may not pay for future skilled therapy services and to provide an estimate of the potential financial liability if Medicare denies coverage. Record review showed that the ABN forms for these residents, issued at the end of their skilled services, were missing the estimated costs section. Administrative staff confirmed that the cost should be presented to allow for the possibility of appeal. The facility's policy indicated that the standard appeals process serves to notify beneficiaries of possible non-coverage and potential financial responsibility, but the omission of estimated costs on the ABN forms meant residents were not fully informed as required.
Failure to Ensure Pharmacist Review and Implementation of Medication Monitoring and Dosage Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the omission of required blood pressure or pulse monitoring prior to the administration of an antihypertensive beta blocker, Carvedilol, for a resident with multiple diagnoses including hypertension, aneurysm of the heart, traumatic brain injury, and transient ischemic attack. The resident had severely impaired cognition and required significant assistance with activities of daily living. The care plan directed staff to monitor for side effects of hypertensive medications and to obtain blood pressure readings as per protocol, but the physician's order for Carvedilol did not specify monitoring requirements, and the CP did not report this omission during monthly drug regimen reviews from April to November. Additionally, the facility did not implement the CP's recommendation regarding the dosage amount for Voltaren gel, a topical medication prescribed for pain. The physician's orders for Voltaren gel on multiple occasions lacked a specified dosage amount for application to the affected areas, particularly for the left shoulder. Although the CP made a recommendation for a dosage amount, the physician's response only addressed the lower extremity and did not specify a dosage for the upper extremity. This resulted in continued orders without clear dosage instructions for all prescribed sites. Interviews with staff revealed uncertainty regarding which antihypertensive medications required monitoring prior to administration, and acknowledgment that all topical medications, including Voltaren gel, require a specified dosage for administration. The facility was unable to provide a policy regarding pharmacy review when requested. These findings demonstrate failures in both the identification and reporting of medication regimen irregularities and the implementation of pharmacist recommendations.
Failure to Monitor Antihypertensive Administration and Specify Topical Medication Dosage
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation for a resident receiving antihypertensive and topical pain medications. Specifically, staff did not obtain blood pressure or pulse readings prior to administering the beta blocker Carvedilol, as required for safe use of this medication class. The physician's order for Carvedilol lacked explicit instructions to monitor these vital signs before administration. Interviews with staff revealed uncertainty regarding which antihypertensive medications required such monitoring, and it was acknowledged by nursing leadership that monitoring should have occurred. Additionally, the facility did not ensure that physician orders for Voltaren gel, a topical pain medication, included clear dosage amounts for application to affected areas. Several orders for Voltaren gel were found to be incomplete, either lacking a specified dosage or omitting the amount to be applied to certain areas, such as the left shoulder. The facility's policy required that all medication orders include the dose and adequate monitoring, but this was not consistently followed for the resident in question, who had multiple complex diagnoses and required significant assistance with activities of daily living.
Expired Injectable Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that injectable medications for one resident were not expired. During an observation of the medication and treatment cart, two Lispro injectable pens with an open date were found for a resident, and it was verified by a licensed nurse that these pens had been put into use on that date and expired 30 days after opening. Both the licensed nurse and an administrative nurse confirmed that the pens should have been discarded after 30 days, as per the facility's policy. The facility's Storage of Medication policy states that discontinued, outdated, or deteriorated drugs must not be used and should be returned to the pharmacy or destroyed according to state regulations.
Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the hospice provider and facility staff for a resident receiving hospice care. The resident, who had diagnoses including hypertension, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and coronary artery disease, required assistance with activities of daily living, supplemental oxygen, and was incontinent. The care plan indicated the resident was on hospice services and included general directives for staff to work with the hospice team and provide comfort, but lacked specific information regarding the hospice provider's contact details, the services and supplies hospice would provide, and the frequency of hospice staff visits. Interviews with facility staff revealed gaps in knowledge and communication about the hospice services. A certified nurse aide stated that nurses typically informed staff about which residents were on hospice and when hospice would visit, but did not have access to the care plan or detailed information about hospice-provided supplies. A licensed nurse was aware the care plan mentioned hospice but could not confirm if it included specifics about supplies or visit schedules. The administrative nurse acknowledged that the care plan should include this information but it was not present at the time of review. The facility's own hospice program policy required collaboration and a coordinated care plan with the hospice provider, including documentation of services, supplies, and visit schedules in the medical record. Despite this policy, the care plan for the resident on hospice did not contain the necessary details to guide staff in coordinating care with the hospice provider, resulting in a deficiency related to the provision and documentation of hospice services.
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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.
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Nursing homes near Wilson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Ellsworth Village | 14.8 mi | ★★★★★ | 1 | 0 |
| Russell Regional Hospital Ltcu | 21.1 mi | ★★★★★ | 19 | 0 |
| Wheatland Nursing & Rehabilitation Center | 21.1 mi | ★★★★★ | 0 | 0 |
| Lincoln Park Manor Inc | 23.6 mi | ★★★★★ | 28 | 0 |
| Azria Health Great Bend | 35.2 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.