Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wilber Care Center during CMS and state inspections, most recent first.
An LPN failed to follow infection control practices during wound care for a resident with diabetes, chronic venous ulcers, and PVD by placing supplies on the resident’s bed, putting soiled items on the recliner and bed, not using required PPE/EBP signage, and not disinfecting supplies before returning them to the cart. Staff also failed to perform proper peri-care and hand hygiene for two residents who were incontinent and dependent for toileting care, including donning and changing gloves without HH, using soiled gloves during wiping, not cleansing the buttocks area, and moving from one resident’s care to another without HH.
Hallway Cluttered With Wheelchairs and Lifts: A resident with dementia who wandered daily and another resident who ambulated with a shuffled gait were observed moving through hallways where multiple wheelchairs, sit-to-stand lifts, a Hoyer lift, and other items were parked along the wall. The DON confirmed the unused equipment should not have been in the hallway and stated the facility had no storage policy for unused lifts or wheelchairs.
The facility did not report suspicions and allegations of abuse or unexplained injuries to the state agency within the required timeframe for two residents. In several cases, bruises were discovered and residents alleged staff involvement, but notifications to APS were delayed beyond the mandated two-hour window after discovery or allegation, as confirmed by the DON.
The facility did not complete annual performance evaluations for four out of five Nurse Aides, potentially affecting all residents. Some MAs had properly signed SERs, while others lacked documentation or had incomplete evaluations. Interviews confirmed the absence of these evaluations.
The facility did not provide the required annual in-service training for three Nurse Aides, potentially affecting all residents. MA D and MA F lacked recent training documentation, while MA E's training hours for 2024 were insufficient. The Administrator confirmed these deficiencies.
The facility failed to ensure proper hand hygiene during peri-care and wound care for three residents. Staff did not change gloves or perform hand hygiene between tasks, and incorrect wiping techniques were used. These lapses were confirmed by staff interviews, highlighting a breach in infection control protocols.
The facility failed to accurately document the Minimum Data Set (MDS) for two residents. One resident, with anxiety, was on lorazepam, but this was not reflected in the MDS. Another resident, with obstructive sleep apnea, used a BiPAP machine, which was also not documented in the MDS. These inaccuracies were confirmed by the MDS Coordinator.
A facility failed to conduct a trauma-based assessment for a resident with severe cognitive impairment and a history of trauma. The resident's CCP lacked trauma information, and the facility did not have a social worker or a specific policy for trauma-informed care. The DON confirmed the absence of trauma-informed care assessments for all residents.
Infection Control Failures During Wound Care and Peri-Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program during wound care for a resident with type 2 diabetes mellitus, chronic venous hypertension with ulcers of both lower extremities, hypertension, and peripheral vascular disease. During observation, an LPN gathered wound care supplies for the resident’s lower extremities and placed Vaseline gauze, gloves, scissors, a dry bordered foam dressing, and A & D ointment directly on the resident’s bed. The LPN washed hands for 15 seconds, used the same paper towel to turn off the water, and then proceeded with wound care. During the wound care, the LPN removed a soiled dressing and placed it on the resident’s recliner seat, completed hand hygiene, and then placed a soiled towel directly on the recliner cushion. The LPN later applied ointment and placed the ointment tube back on the resident’s bed, painted open areas with betadine, and placed a soiled glove directly on the resident’s bed. The LPN also placed used wound care items back into the treatment cart without first disinfecting them. The observation also showed no Enhanced Barrier Precautions signage on the resident’s door or inside the room, and only gloves were present in the room with no other PPE noted. The LPN confirmed that the soiled dressing, towel, and glove should not have been placed on the recliner or bed and that a gown should have been worn during wound care. The DON confirmed the door should have had an EBP sign, PPE should have been in the room, hand washing should have been at least 20 seconds, and the soiled items should not have been placed on the recliner or bed. The facility also failed to perform peri-care and hand hygiene in accordance with policy for two residents who required assistance with toileting and hygiene. For one resident with cognitive impairment, incontinence, and dependence for toileting hygiene, staff donned gloves without hand hygiene, changed gloves without hand hygiene, used the same soiled gloves while wiping the perineum with multiple wipes, and did not cleanse the buttocks area before applying a new brief. Staff also continued care and moved equipment in and out of the room without hand hygiene. For another resident with urge incontinence, dementia, and dependence for toileting and transfers, staff entered the room and donned gloves without hand hygiene, removed a soaked brief, changed gloves without hand hygiene, wiped the resident front to back with two wipes without using a new wipe or cleansing the buttocks or hips, and later moved directly from that resident’s room to another resident’s room without any hand hygiene. The DON confirmed the staff did not follow the peri-care and hand hygiene policy and stated that no peri-care audits were being done to provide oversight.
Hallway Cluttered With Wheelchairs and Lifts
Penalty
Summary
The facility failed to keep a hallway free from accident hazards and to provide adequate supervision for ambulatory residents. Resident 32 was admitted on 02/07/2025 and, according to the 05/07/2026 MDS, had moderately impaired cognition, wandered daily, and had vascular dementia, Alzheimer's disease, and anxiety. The care plan noted that Resident 32 wandered without purpose and directed staff to redirect the resident and avoid over stimulation. Progress notes also documented that Resident 32 was wandering with a front wheeled walker on 05/01/2026 and had been confused, pacing the hallways, and anxiously looking for family on 05/16/2026. During multiple observations, residents were seen moving through hallways where equipment was stored along the wall, including several wheelchairs, sit-to-stand lifts, a Hoyer lift, and a tray table with an office chair and wireless keyboard. Resident 8 was observed near a laundry cart in the hall and later wandering up and down the 100 hall, and Resident 32 was observed sitting near the nurse's desk while the hallway remained lined with equipment. On 05/20/2026, Resident 32 was ambulating with a front wheeled walker beside the beautician, and staff had to wait to pass until they moved beyond the wheelchairs lined against the wall. Later that day, Resident 8 was observed ambulating down the hallway with a shuffled gait while wheelchairs and lifts remained parked in the same hallway. The DON confirmed that unused wheelchairs and lifts should not be in the hallway because they were a safety concern for residents who ambulated, and stated the facility did not have a storage policy for lifts or wheelchairs not in use.
Failure to Timely Report Suspected Abuse and Injuries
Penalty
Summary
The facility failed to report suspicions and allegations of abuse, neglect, or theft to the state agency within the required timeframe for two residents. In multiple instances, bruises of unknown origin were discovered on residents, and in some cases, residents alleged that the injuries were caused by staff members during care activities such as transfers. The Director of Nursing (DON) did not observe or follow up on the injuries promptly, and the incidents were not reported to Adult Protective Services (APS) within the mandated two-hour window after discovery or after an allegation was made. Specifically, one resident was found with a bruise on the right back/hip, and the DON did not observe the area until the following day, with the report to APS occurring more than two hours after discovery. Another resident was found with a bruise on the right hip and later alleged that a nurse aide had caused the injury; this was also reported to APS more than two hours after the allegation. In a third instance, a bruise on a resident's left thigh was discovered, and after the resident stated that a nurse aide had pushed on their thigh during a transfer, the report to APS was delayed several days. In all cases, the DON confirmed that the reports were not made within the required timeframe.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five Nurse Aides sampled, which had the potential to affect all residents in the facility. The facility's census was 37. A record review revealed that while some Medication Aides (MAs) had Staff Evaluation Reports (SERs) signed by both the evaluator and the employee, others either lacked an SER or had an SER that was not properly documented. Specifically, MA E had no SER available, and MA K's SER was signed only by the evaluator without documentation of discussion with the employee. Interviews with the Director of Nursing and the Business Office Manager confirmed the absence of annual performance evaluations for the Nurse Aides and MAs.
Deficiency in Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide the required annual in-service training for three out of five sampled Nurse Aides, which had the potential to affect all residents in the facility with a census of 37. Specifically, a review of the User Learning documents revealed that Medication Aide (MA) D had no documentation of any training completed after October 8, 2022, and MA F had no documentation of training completed after May 4, 2023. Additionally, MA E's training record for 2024 showed a total of only 6.25 hours, which is less than the required 12 hours. An interview with the Administrator confirmed these findings, indicating a lack of compliance with the annual in-service training requirements as per Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1).
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during peri-care and wound care, affecting three residents. For Resident 8, a medication aide and a nurse aide did not change gloves or perform hand hygiene after removing a soiled brief and before handling a clean one, nor did they perform hand hygiene between different stages of peri-care. This oversight was confirmed by the medication aide during an interview. Resident 25's peri-care was also compromised as a medication aide washed their hands for only 6 seconds, contrary to the facility's policy of 15 seconds. The aide did not perform hand hygiene between glove changes and incorrectly wiped the resident's peri-area from back to front, which was acknowledged during an interview. Additionally, the aide did not know the correct duration for handwashing and failed to sanitize hands when changing gloves. For Resident 12, the Director of Nursing did not perform hand hygiene between changing gloves during wound care, as they believed it was unnecessary since their hands were not visibly soiled. This was confirmed during an interview. The facility's infection preventionist and the Director of Nursing acknowledged the lapses in hand hygiene and the correct procedures that should have been followed.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two residents, affecting the comprehensive assessment of their functional capabilities. Resident 8, who was diagnosed with anxiety, had an order for lorazepam, an anti-anxiety medication, which was administered during the look-back period. However, the MDS did not reflect the use of this medication, as confirmed by the MDS Coordinator. This oversight indicates a failure to accurately document the resident's medication use in the MDS. Similarly, Resident 18, diagnosed with obstructive sleep apnea, had an order for a BiPAP machine to be used every evening. The BiPAP was administered during the look-back period, but the MDS did not indicate the use of this non-invasive mechanical ventilator. The MDS Coordinator confirmed that the BiPAP should have been coded on the MDS. These inaccuracies in the MDS documentation for both residents highlight a deficiency in the facility's assessment process.
Failure to Conduct Trauma-Based Assessment for Resident
Penalty
Summary
The facility failed to complete a trauma-based assessment for a resident, identified as Resident 7, who was part of a sample of five residents. The facility's census was 37 at the time of the survey. Resident 7's Minimum Data Set (MDS) indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 1, and diagnoses of anxiety, depression, and frequent pain. Despite these indicators, the resident's Comprehensive Care Plan (CCP) did not include a history of trauma. An interview with the resident's representative revealed that the resident had been attacked by a cow years ago, which had a significant impact on them. The Director of Nursing (DON) confirmed that no trauma-informed care assessments had been completed for any residents, and trauma was not identified in Resident 7's CCP. Additionally, the facility lacked a social worker at the time. The facility's policy on Comprehensive Care Plans, dated March 2024, defined trauma-informed care but did not have a specific policy or assessment for trauma-informed care. The DON confirmed the absence of a facility policy regarding trauma-informed care or a facility trauma-based assessment.
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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 Wilber
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Crete | 9.5 mi | ★★★★★ | 6 | 0 |
| Beatrice Health And Rehabilitaion | 18.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Beatrice | 19.9 mi | ★★★★★ | 12 | 0 |
| Milford Meadows Care Center | 19.9 mi | ★★★★★ | 1 | 0 |
| Gold Crest Retirement Center | 23.1 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 July 2026) and official state health department websites.