Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Wilson Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment in an LTC facility exhibited aggressive and sexually inappropriate behaviors towards other residents, leading to multiple incidents of abuse. Despite these occurrences, the facility failed to notify state agencies, families, and physicians, and did not assess affected residents for injuries. The facility's policies on abuse reporting and prevention were not followed, contributing to ongoing risks.
Two residents in the facility experienced worsening of pressure ulcers due to the failure to obtain timely wound care orders. One resident, with a history of traumatic brain injury and diabetes, developed an unstageable pressure ulcer on the right hip, while another resident with heart disease and dementia had a blood blister on the right heel. Despite being at high risk for pressure sores, the facility did not implement appropriate wound care, and staff failed to secure necessary orders, leading to the deterioration of the residents' conditions.
The facility did not submit direct care staffing payroll data for PBJ reporting for Quarter 2. The administrator stated that the Director of Operations tried to submit the data but missed the deadline, resulting in the system being locked. The Director of Operations confirmed that the data was collected but not submitted as the system was closed.
The facility failed to report multiple incidents of abuse and neglect involving residents to state agencies, as required by policy. A resident with dementia and explosive disorder was involved in several unreported incidents of physical and sexual aggression towards other residents. Additionally, a fall resulting in a major injury was not reported. The facility did not notify families of the incidents, and no new interventions were implemented to address ongoing aggressive behaviors.
A facility failed to investigate and report multiple incidents of resident-to-resident abuse and sexual abuse involving a resident with dementia and explosive disorder. Despite documented aggressive and inappropriate behaviors, no incident reports were filed, and state agencies were not notified. The facility's policy on reporting abuse was not followed, as confirmed by interviews with the DON and Administrator.
The facility failed to properly label and store food items according to policy. During a survey, it was observed that food items in the refrigerator were undated and unlabeled, contrary to the facility's Safe Food Handling policy. A Dietary Aide confirmed that items like bacon, hashbrowns, and steak fingers were stored without labels or dates, despite the requirement for proper labeling to prevent cross-contamination.
A facility failed to implement enhanced barrier precautions for a resident with a suprapubic catheter, resulting in a deficiency in infection prevention and control. The resident, diagnosed with dementia and acute kidney disease, was observed without proper signage or PPE for EBP. The IPC nurse admitted to not using gowns and only recently learning about EBP precautions, which were not implemented during care.
The facility failed to document accurate code status and advance directives for two residents. One resident's electronic health record lacked a code status, and their hard chart did not have a signed DNR, despite a sticker indicating DNR. Another resident, with dementia, had no documented advance directives, and their representative did not provide a living will or DNR order upon admission. This resulted in a lack of directives for medical emergencies.
A facility failed to document the assessment and death record for a resident with Congestive Heart Failure. The DON reported the absence of these records, which was confirmed during a review and interview process. This issue affected one of the 28 residents in the facility.
A facility failed to update a resident's care plan to reflect hospice services, despite the resident having been admitted to hospice care. The resident had diagnoses including heart disease, type two diabetes mellitus, and acute kidney failure. An LPN confirmed the absence of hospice documentation in the care plan during a review.
An LPN failed to verify physician orders before administering medications to two residents. One resident with chronic conditions received a Ventolin inhaler, and another with diabetes and dementia received Tresiba insulin without order verification. The LPN admitted to not checking the orders, citing routine practice and lack of updates during shift change.
The facility failed to obtain laboratory tests as ordered for two residents. One resident with diabetes and dementia had a missing C-Peptide result despite an order, while another resident with multiple conditions had no follow-up on a lab order that was not collected. Staff confirmed the absence of results in both cases.
A facility failed to document and educate a resident with high blood pressure and depression about influenza and pneumococcal vaccinations. The resident's records lacked documentation of consent or refusal for immunizations, and the IPC nurse confirmed the absence of such documentation. Additionally, the resident's representative was not educated about the immunizations, a task usually performed by Social Services upon admission.
A facility failed to screen, offer, and educate a resident on the COVID-19 vaccination, as required by their policy. There was no documentation of the resident receiving the vaccine or any record of consent or refusal. The IPC nurse confirmed the lack of documentation and stated that education on immunizations was not provided to the resident's representative, which was usually done by Social Services upon admission.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with severe cognitive impairment who exhibited aggressive and sexually inappropriate behaviors towards other residents. This resident, diagnosed with dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in multiple incidents of physical and sexual abuse against other residents, all of whom had moderate to severe cognitive impairments. The incidents included hitting and inappropriate sexual touching, which were documented in progress notes and assessments. Despite the repeated occurrences of abuse, there was a lack of documentation indicating that all necessary parties, including state agencies, families, and physicians, were notified of these incidents. Additionally, there was no evidence that the affected residents were assessed for injuries following the altercations. The facility's failure to report these incidents and assess the residents for injuries highlights a significant deficiency in their abuse prevention and reporting protocols. The facility's policies on abuse, which mandate thorough investigation and documentation of suspected abuse, were not adhered to. The DON and Administrator acknowledged that the incidents were not reported as required, and the behaviors of the aggressive resident were not discussed in the facility's QA meetings. This oversight contributed to the ongoing risk of harm to residents, as the aggressive behaviors were not adequately addressed or mitigated.
Removal Plan
- Immediate action to protect residents at risk from abuse from Resident #3.
- Agreement between the facility and a hospital to take Resident #3 for evaluation and treatment to remove any threat of harm.
- Resident #3 taken to the hospital by a family member.
- Staff responsible for reporting and documenting suspected abuse will receive additional training.
- Care Plan for Resident #3 will be updated to reflect behavioral issues and necessary interventions.
- Facility policy regarding abuse reviewed by members of the IDT.
- Additional training regarding abuse, prevention, reporting, and chain of command will be completed with all staff.
- Nurses will receive training specific to their duties and responsibilities.
- If Resident #3 returns to the facility, a staff member will be assigned by the Charge Nurse to conduct one-on-one monitoring of the resident to ensure they are prevented from harming or abusing other residents until final discharge.
- Policy review and staff training regarding abuse and facility policies and procedures will be completed.
Failure to Provide Timely Wound Care Orders
Penalty
Summary
The facility failed to ensure timely wound care orders for two residents, leading to the worsening of their conditions. Resident #10, who had a history of traumatic brain injury, type two diabetes mellitus, dementia, and muscle weakness, developed an unstageable pressure ulcer on the right hip. Despite being at risk for pressure sores, as indicated by a Braden Scale assessment, the facility did not obtain or implement appropriate wound care orders in a timely manner. The resident's condition was documented to have worsened over time, with multiple notes indicating the presence of pressure sores and the lack of effective treatment. Resident #17, diagnosed with heart disease, dementia, and chronic kidney disease, was also affected by the facility's failure to provide adequate wound care. The resident was identified as high risk for pressure sores, yet there was no documentation of a skin assessment or wound care from mid-July until the end of the month. The resident's right heel developed a blood blister, and despite the presence of dressings provided by hospice, there were no physician orders or documentation of treatment being administered. The facility's staff, including LPNs and the DON, were aware of the residents' conditions but failed to take appropriate action to secure necessary wound care orders. Communication issues with hospice and a lack of proactive measures to obtain orders from the facility's medical director contributed to the deficiency. The facility's inaction resulted in the worsening of the residents' wounds, as evidenced by the observations and interviews conducted during the survey.
Removal Plan
- Immediate action was taken to protect residents at risk of serious injury, harm, impairment or death.
- Orders were obtained for the appropriate wound care.
- All nursing staff, including hospice personnel, were notified of the deficient practice and educated on the importance of timely, and effective communication.
- Nursing Center staff was educated on obtaining orders from facility Medical Director in the event of not being able to obtain orders from a hospice medical director.
- Baseline skin assessment completed and documented on all residents residing in the facility.
- Facility policy regarding wound care was reviewed by members of the IDT.
- Nursing Center will perform weekly skin assessments on all residents and document in skin assessments as well as in narrative format.
- Any resident with a known wound will have photo documentation under the miscellaneous tab in the EHR.
- Additional training regarding skin integrity, wound prevention, reporting, and chain of command will be completed with ALL staff by the in-service training.
- The Director of Nurses will perform chart audits and QA all orders and notes on every patient.
- The Director of Nurses will delegate chart audits to a registered nurse to assist in accurate and timely documentation.
- Residents having an area of concern or wound will be assessed and documented.
- Resident care plans will be updated to reflect the area of concern with skin integrity.
- Results of the audits will be reviewed by the QA Committee.
- Orders were received upon notification of the deficient practice.
- Nursing Center will educate and in-service all ancillary staff, to include hospice providers on orders being received and in place.
- Policy review and staff training regarding wound care and facility policies and procedures will be completed.
Failure to Submit PBJ Staffing Data for Quarter 2
Penalty
Summary
The facility failed to submit direct care staffing payroll data for the PBJ report for the period from January 1, 2024, to March 31, 2024, which corresponds to Quarter 2. This deficiency was identified through record review and interviews. The PBJ Staffing Data Report indicated that the data for this quarter was not submitted. During an interview on August 2, 2024, the administrator explained that the Director of Operations attempted to report the data but was unable to do so because the system was locked, and they had missed the submission deadline. On August 5, 2024, the Director of Operations confirmed that although the data was collected, the submission was not completed as the system was closed.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of abuse, neglect, and theft to the appropriate state agencies, as required by their policy. Specifically, the facility did not file incident reports for allegations of physical abuse involving four residents, allegations of sexual abuse involving four residents, and a fall resulting in a major injury for one resident. The facility's policy, dated September 2005, mandates that suspected or substantiated cases of resident abuse be thoroughly investigated, documented, and reported to state agencies. However, this protocol was not followed in multiple instances. Resident #3, who has diagnoses including dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in several incidents of physical and sexual aggression towards other residents. Despite documented aggressive behaviors and altercations with other residents, such as hitting and inappropriate touching, there was no evidence that these incidents were reported to state agencies. Additionally, Resident #3's care plan and behavior logs indicated ongoing aggressive and sexually inappropriate behaviors, yet no new interventions were implemented after July 8, 2024, to address these issues. The facility also failed to notify the families of the residents involved in these incidents. For example, the family of Resident #30 was not informed about the inappropriate interactions with Resident #3. Furthermore, the facility did not report a fall incident involving Resident #3 that resulted in a fractured pelvis. The Director of Nursing (DON) and the Administrator acknowledged that these incidents should have been reported, but there was no documentation to confirm that state reports were filed. The lack of reporting and documentation highlights a significant deficiency in the facility's adherence to its abuse reporting policy.
Failure to Investigate and Report Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident abuse and sexual abuse involving multiple residents. Resident #3, who had diagnoses including dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in several incidents of physical aggression towards other residents, such as hitting and cursing. Despite these documented incidents, there was no evidence that incident reports were filed or that state agencies were notified. Additionally, the care plan for Resident #3 did not include new interventions to address these behaviors. Resident #3 was also involved in several incidents of sexually inappropriate behavior towards other residents, including touching and rubbing inappropriately. These behaviors were documented in behavior notes, but there was no indication that the facility took appropriate action to report these incidents to state agencies or notify the families of the affected residents. The facility's policy on reporting abuse, neglect, or mistreatment was not followed, as the incidents were not thoroughly investigated or documented. Interviews with the Director of Nursing (DON) and the Administrator revealed that the incidents were not reported as required by the facility's abuse policy. The DON acknowledged that the incidents should have been reported, and the Administrator confirmed that resident-to-resident abuse and sexual abuse should be reported, especially when the residents involved are unable to consent. The lack of documentation and reporting of these incidents indicates a failure to adhere to the facility's policies and procedures for handling allegations of abuse.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to ensure that food items were properly labeled and stored according to their policy, as observed and reported during a survey. The facility's Safe Food Handling policy from the WNC Dietary Department, although undated, specifies that all food items must be labeled correctly to prevent cross-contamination and ensure proper identification. Labels should include the product name, preparation or expiration date, storage instructions, and any allergen information. However, during an observation on July 28, 2024, at 9:06 a.m., it was noted that there were undated and unlabeled food items in the refrigerator. At 9:07 a.m., a Dietary Aide reported that bacon, hashbrowns, and steak fingers were stored in the refrigerator without labels or dates. The Dietary Aide confirmed that the food is supposed to be stored with proper labeling and dating.
Failure to Implement Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a suprapubic catheter, leading to a deficiency in infection prevention and control. The resident had diagnoses including dementia, bladder neck obstruction, and acute kidney disease, with physician orders for catheter care and irrigation. During an observation, the resident was found in bed with a catheter bag hanging on the edge, but no signage for EBP precautions or personal protective equipment (PPE) was present near the resident's door. The Infection Prevention and Control (IPC) nurse admitted to not using gowns and only recently learning about EBP precautions, indicating that these precautions were not implemented during wound and catheter care. The nurse provided a CMS memo regarding EBP precautions, which they had reviewed.
Deficiency in Documenting Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that the clinical health records accurately reflected the code status and advance directives for two residents. Resident #27, who had diagnoses including atrial fibrillation and pain, did not have a documented code status in their electronic health record, and their hard chart lacked a signed Do Not Resuscitate (DNR) order. Despite a white sticker on the spine of the chart indicating DNR, there was no formal documentation to support this status. When questioned, the Infection Prevention and Control (IPC) nurse was uncertain of the resident's code status, and the Social Services Director (SSD) confirmed the absence of a DNR in the hard chart. Resident #27 themselves stated they were a DNR, highlighting the discrepancy between the resident's understanding and the facility's documentation. Resident #30, diagnosed with dementia, also lacked proper documentation of advance directives. The facility's records indicated that the review of Resident #30's advance directives was postponed, with no follow-up action documented. The SSD reported that at the time of admission, Resident #30's representative did not provide a living will or DNR order. Consequently, the facility had no directives to follow in the event of a medical emergency for Resident #30, as confirmed by the SSD. This lack of documentation and follow-up on advance directives for both residents demonstrates a failure to adhere to the facility's policy and procedure regarding residents' rights to formulate advance directives.
Failure to Document Resident Assessment and Death Record
Penalty
Summary
The facility failed to ensure the coordination of resident assessment and death record for a resident diagnosed with Congestive Heart Failure. On the morning of August 1st, there was no documentation available for the resident's death record or assessment. The Director of Nursing (DON) had previously reported the absence of these records on July 31st. This deficiency was identified during a review of records and interviews, affecting one of the 28 residents residing in the facility.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update the care plan for a resident to reflect that hospice services were in place. This deficiency was identified during a record review and interview process. The resident in question had diagnoses including heart disease, type two diabetes mellitus, and acute kidney failure. A hospice progress report documented that the resident was admitted to hospice services on January 3, 2024. However, the resident's care plan did not document that they were receiving hospice services. On August 5, 2024, an LPN was asked if the care plan documented the resident's hospice services, and upon review, the LPN stated that they did not see such documentation.
Failure to Verify Physician Orders Before Medication Administration
Penalty
Summary
The facility failed to ensure that staff reviewed physician orders prior to administering medications for two residents. Resident #22, who had diagnoses including chronic obstructive pulmonary disease and chronic kidney disease, was observed receiving a Ventolin inhaler without the LPN checking the physician's order beforehand. The physician's order, dated June 4, 2023, specified the administration of the Ventolin inhaler two puffs by mouth twice daily. However, during the medication observation on August 1, 2024, the LPN did not verify the order before administering the medication. Similarly, Resident #14, diagnosed with type two diabetes mellitus and dementia, was administered Tresiba insulin without the LPN checking the physician's order. The physician's order, dated May 18, 2024, required the administration of ten units of Tresiba insulin subcutaneously once a day. On the same day of observation, the LPN administered the insulin without verifying the order. When questioned, the LPN admitted to not checking the orders for both residents, stating they were accustomed to their routine and had not received any updates during the shift change.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by the physician for two residents. Resident #3, who had diagnoses including type two diabetes mellitus and dementia, had a physician order to obtain a HGB A1c and a C-Peptide lab on July 1st. However, the order was not noted by a nurse, and although the HGB A1c was obtained and resulted at 9.3, there was no documentation of the C-Peptide results. Despite inquiries, the facility did not provide any further documentation for the C-Peptide lab results. Resident #20, diagnosed with generalized edema, high blood pressure, and type two diabetes mellitus, had a physician order to obtain a CBC, CMP, CNP, CRP, and sed rate. The treatment administration record indicated a 9 on the date the labs were ordered, but a progress note later documented that the lab was unable to be collected and would be redrawn at a later date. However, there was no follow-up, and the clinical health record did not contain documentation that the lab had been obtained. Staff members confirmed they had not seen any lab results for the physician order.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that residents were screened, offered, and educated about the risks and benefits of influenza and pneumococcal vaccinations. Specifically, one resident, who had diagnoses including high blood pressure and depression, was not documented as having received any immunizations. There was no documentation in the electronic health record or the hard chart indicating that the resident or their representative had consented to or refused the immunizations. The Infection Prevention and Control (IPC) nurse confirmed the absence of a consent or refusal form and stated that such documentation should be present in either the computer or the hard chart. Additionally, the IPC nurse acknowledged that the resident's representative had not been educated about the immunizations, which is typically done by Social Services (SS) upon the resident's admission.
Failure to Document and Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to screen, offer, and educate a resident on the risks and benefits of the COVID-19 vaccination. The facility's policy and procedure for immunizations, which was undated, required following CDC and local health department guidelines and providing educational materials about the benefits and potential side effects of the vaccines. However, for one resident, there was no documentation in the electronic health record or hard chart indicating that the resident had received any immunizations, nor was there any record of consent or refusal for the COVID-19 vaccine. The Infection Prevention and Control (IPC) nurse confirmed the absence of documentation for consent or refusal and stated that it should have been recorded either in the computer or the hard chart. Additionally, the IPC nurse admitted that the resident's representative had not been educated about the immunizations, which was typically done by Social Services (SS) upon the resident's admission. This oversight affected one of the five sampled residents reviewed for immunizations, out of a total of 28 residents in the facility.
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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) |
|---|---|---|---|---|
| Elmbrook Home | 15.5 mi | ★★★★★ | 4 | 0 |
| Southbrook Healthcare, Inc | 16 mi | ★★★★★ | 0 | 0 |
| Ardmore Center For Rehabilitation And Healthcare | 17 mi | ★★★★★ | 0 | 0 |
| Woodview Home, Inc. | 18 mi | ★★★★★ | 2 | 0 |
| Lake Country Nursing Center | 22.5 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.