Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wilson Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was injured when a contracted transport team pushed her stretcher over uneven pavement and it tipped sideways, after which she developed pain and x-ray findings showed right rib fractures. In a separate incident, a cognitively intact resident was discharged with her own meds plus another resident’s cyclobenzaprine packet, which the resident later reported to the facility. The DON retrieved the misplaced meds, and the NP noted the drug was not prescribed for that resident.
Failure to Document Advance Directive Education and Offer: The facility did not document written advance directive information or an opportunity to formulate an advance directive for three residents reviewed. The residents had stroke diagnoses and DNR code status orders, with cognitive status ranging from intact to severely impaired on MDS assessments. Staff interviews showed the focus was mainly on code status and obtaining copies of existing documents, and these conversations were not documented in the medical record.
A resident was discharged with another resident's medication packet, and the packet was labeled with the other resident's name, creating a privacy concern. The LPN who completed the discharge said she gathered the resident's meds and provided them at discharge, but later learned a packet of cyclobenzaprine for another resident had been included. The DON confirmed the error after the discharged resident called the facility to report it.
The facility’s medication error rate was 6.9%, with 2 errors found in 4 observed med passes. One nurse gave an insulin dose without priming the pen first, and another did not ensure a resident rinsed and spit after using a steroid-containing inhaler. The residents involved had DM and COPD, respectively, and both were moderately cognitively impaired.
Staff failed to follow infection control protocols by not donning gowns when entering the rooms of a resident on Contact Precautions and another resident with a gastrostomy tube under Enhanced Barrier Precautions. The SDC and a nurse both entered rooms with required signage and provided care or administered medication without wearing gowns, contrary to facility policy.
A resident who remained in the facility after Medicare Part A skilled services ended did not receive the required CMS SNF-ABN and NOMNC forms, as confirmed by record review and interviews with the responsible party and staff. The Social Worker, new to her role at the time, did not issue the forms, and the deficiency was only identified after the fact by the DON and Administrator.
Two residents had inaccuracies in their MDS assessments: one was incorrectly coded as discharged to the hospital instead of home, and another was not coded for dialysis despite receiving regular treatments. These errors were confirmed through record review and staff interviews.
Unsafe Transport and Discharge Medication Mix-Up
Penalty
Summary
The facility failed to ensure safe transportation for a resident when a contracted medical transport team was pushing her stretcher through an Imaging Center parking lot after an appointment and the right wheel hit an uneven section of pavement. The stretcher tipped to the right, and the two transport technicians and a passerby had to stabilize it. The resident remained secured to the stretcher and did not fall, but after returning to the facility she complained of pain. Staff later documented increased pain, and an x-ray showed acute fractures of the right 4th through 6th ribs. The resident had multiple pre-existing conditions, including a displaced left humerus fracture, a left hip fracture, COPD, CAD, kidney disease, atrial fibrillation, hypertension, hyperlipidemia, and documented pain issues before the transport event. The resident’s record showed orders for PRN acetaminophen and topical menthol analgesic, along with monitoring of pain and vital signs. Her MDS reflected moderate cognitive impairment, dependence on staff for all ADLs, and frequent episodes of severe pain. After the transport incident, nursing staff documented that the resident complained of back and shoulder pain, and family reported that she said, "damn, they hurt me." The NP later ordered imaging after the pain worsened, and the x-ray confirmed the rib fractures. The resident then required additional pain management, including tramadol and later scheduled acetaminophen and a Lidoderm patch. The facility also failed to prevent a medication error at discharge when a cognitively intact resident was sent home with another resident’s medication. The discharge nurse documented that all belongings and medications were provided to the resident, but the resident later called the facility and reported that she had also received a packet containing 14 tablets of cyclobenzaprine 5 mg prescribed for another resident. The DON retrieved the medication from the resident’s home after the error was reported. The resident was not prescribed cyclobenzaprine, and the NP stated that if taken it could cause muscle weakness, drowsiness, and increased fall risk.
Failure to Document Advance Directive Education and Offer
Penalty
Summary
The facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 3 of 7 residents reviewed. Resident #8 was admitted with a diagnosis of stroke, had a physician order for DNR code status, and was cognitively intact on the annual MDS assessment, but there was no documentation in the medical record showing education about advance directives or that an opportunity to formulate one was offered. Resident #9 was admitted with a diagnosis of stroke, had a physician order for DNR code status, and was moderately cognitively impaired on the significant change MDS assessment, but there was no documentation of advance directive education or an offer to formulate one. Resident #14 was admitted with a diagnosis of stroke, had a physician order for DNR code status, and was severely cognitively impaired on the annual MDS assessment, but there was no documentation in the medical record of education regarding advance directives or that an opportunity to formulate one was offered. Interviews with the Admissions Director, Social Worker #1, Social Worker #2, and the Administrator indicated that discussions focused mainly on code status and obtaining copies of existing documents such as a living will or health care power of attorney, and these conversations were not documented in the residents' medical records.
Resident Medication Sent Home With Wrong Discharge Packet
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when a medication prescribed for one resident was sent home with another resident at discharge. Resident #127 was discharged from the facility with a friend, and Nurse #5 documented that all belongings and medications were provided to the resident with education. Later, Resident #127 called the facility and reported that one packet of medication for another resident had also been given to her. Nurse #5 stated she had gathered Resident #127's medications at discharge and later learned that a packet belonging to Resident #131 had been included. The Director of Nursing confirmed that the packet contained fourteen 5 mg cyclobenzaprine tablets labeled with Resident #131's name and that it had been sent home with Resident #127. The Director of Nursing stated she went to Resident #127's home to retrieve the medication, and the Administrator confirmed that a pack labeled with Resident #131's name was sent home with Resident #127 and that this was a privacy concern.
Medication Error Rate Exceeded Threshold; Insulin Pen Not Primed and Inhaler Rinse Not Completed
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with a measured medication error rate of 6.9 percent. During observation, record review, and staff interviews, surveyors identified 2 medication administration errors out of 4 observed administrations: one involving an insulin pen that was not primed before the ordered dose was given, and one involving an inhaled steroid medication where the resident was not instructed or assisted to rinse her mouth with water without swallowing after use. Resident #38 had diabetes mellitus and was moderately cognitively impaired. A physician ordered insulin degludec 58 units subcutaneously once daily. During observation, a nurse obtained the insulin pen, attached the needle, dialed the pen to 58 units, and administered the injection without first priming the pen. The nurse later stated she normally primes insulin pens but forgot to do so while being observed. Staff Development, the DON, the NP, and the Administrator all confirmed that the pen should have been primed according to the manufacturer’s instructions before the dose was administered. Resident #50 had COPD and was moderately cognitively impaired. A physician ordered fluticasone furoate, umeclidinium, and vilanterol aerosol powder, 1 puff daily, with instructions to rinse the mouth after use. During observation, the resident used the inhaler, but the nurse did not provide water or instruct the resident to rinse and spit afterward; instead, the resident was given laxative solution mixed with water and drank it. The nurse acknowledged she did not offer or encourage the rinse and stated the resident had refused in the past, but those refusals had not been documented or reported. The DON, NP, and Administrator confirmed that the mouth rinse should have been offered and that prior refusals should have been documented and communicated.
Failure to Follow Infection Control Protocols for Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and posted signage. In one instance, the Staff Development Coordinator (SDC) entered the room of a resident on Contact Precautions wearing gloves but did not don a gown, despite clear signage and facility policy requiring a gown to be worn when entering such rooms. While in the room, the SDC assisted the resident in getting comfortable in bed and disposed of a soiled tissue, then removed gloves and performed hand hygiene before leaving. The SDC later acknowledged the error after reviewing the posted precautions. In a separate incident, a nurse entered the room of a resident with a gastrostomy tube and an Enhanced Barrier Precautions (EBP) sign posted, to administer medication via the tube. The nurse performed hand hygiene and wore gloves but did not wear a gown, contrary to facility policy that requires both gown and gloves for high-contact care activities involving indwelling medical devices. The nurse stated she was told by another nurse that a gown was not necessary, but could not recall who provided this information. Both the Quality Improvement Nurse and the Director of Nursing confirmed that a gown should have been worn in this situation.
Failure to Provide Required Medicare Beneficiary Notification Forms
Penalty
Summary
The facility failed to provide required Centers for Medicare and Medicaid Services (CMS) beneficiary notification forms to a resident when Medicare Part A skilled services were discontinued, despite the resident not having exhausted all available benefit days. Specifically, the resident was admitted under Medicare Part A and continued to reside in the facility after skilled services ended, but there was no evidence in the medical record that the CMS SNF Advanced Beneficiary Notification (ABN) or the Notice of Medicare Non-Coverage (NOMNC) forms were issued at the time services ended. Interviews with the Business Office Manager confirmed the resident had not used all covered days, and the Responsible Party reported not receiving the required forms. Further interviews revealed that the Social Worker, who was responsible for issuing these forms, was new to her position at the time and did not recall providing the notifications. The DON became aware that the forms were not being issued and informed the Social Worker of her responsibility, but this occurred after the deficiency for the resident in question. The Administrator also confirmed the Social Worker’s inexperience contributed to the failure to provide the required notifications.
Inaccurate MDS Coding for Discharge and Dialysis
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of discharge and dialysis. For one resident, the discharge MDS assessment was completed and incorrectly indicated that the resident was discharged to the hospital. However, both the nurse's note and interviews with the responsible party and staff confirmed that the resident was actually discharged home. The MDS nurse acknowledged that the assessment was miscoded due to the resident leaving a day earlier than expected, leading to the use of an incorrect discharge code. For another resident with end stage renal disease, the admission MDS assessment did not reflect that the resident was receiving dialysis, despite a physician's order for regular dialysis treatments at an offsite clinic. The MDS Coordinator admitted awareness of the resident's dialysis and stated that the omission was an oversight. Both deficiencies were confirmed through record review and staff interviews.
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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) |
|---|---|---|---|---|
| Wilson Healthcare And Rehabilitation Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Harmony Park At Wilson | 0.6 mi | ★★★★★ | 1 | 0 |
| Wilson Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Longleaf Neuro-medical Treatment Center | 2.7 mi | ★★★★★ | 4 | 0 |
| Autumn Care Of Nash | 17.6 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.