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 Wilmot Care Center Inc during CMS and state inspections, most recent first.
A whirlpool tub in a nursing home was found to have an active water leak near a 120-volt electrical box, creating a potential hazard. The facility's administrator, DON, and facility manager were unaware of the issue, and the tub was still in use for resident bathing. Despite the CNA's verbal reports of the leak, no formal work order was submitted, and the maintenance log lacked recent entries. The tub's condition, including rust and removed control panel doors, indicated neglect in maintenance, leading to an immediate jeopardy situation.
The facility failed to meet residents' nutritional needs by not following the dietician-approved menu. The lunch served lacked coleslaw, and the dietary manager was unaware of the missing item. The cook did not report the issue or substitute the missing item, resulting in residents being underserved one serving of vegetables. The administrator was unaware of the discrepancy, and there was no policy for menu changes.
The facility failed to properly label and store food items, leading to expired and improperly dated products in the kitchen. Observations revealed unlabeled sandwiches, expired lemon juice, Italian dressing, sour cream, cheese, and milk, as well as rotting tomatoes. Interviews with staff indicated a lack of awareness and responsibility for checking expiration dates, and the dietary manager admitted to not having a regular inspection schedule. The administrator expressed frustrations with the kitchen's operations.
The facility failed to follow infection control policies for a resident with MRSA and two residents with indwelling catheters. Staff did not consistently use enhanced barrier precautions (EBP) such as gowns and gloves during care. Observations showed a lack of signage and PPE availability, and interviews revealed staff confusion about EBP requirements. The facility's policy required EBP for residents with MDROs and indwelling devices, but care plans did not reflect this need.
A resident with moderate cognitive impairment and at risk for pressure ulcers was not consistently provided with prescribed Prevalon boots, leading to the development of pressure ulcers on both heels. Despite doctor's orders and care plans, staff frequently failed to ensure the resident wore the boots, as confirmed by multiple observations and staff interviews.
A resident with Alzheimer's and nutritional issues was given a sandwich despite a speech therapy recommendation for a pureed diet. The care plan was not updated to reflect the physician-ordered dietary change, and the dietary manager failed to revise the care plan as required by facility policy.
A resident with severe cognitive impairment and swallowing difficulties was fed a peanut butter and jelly sandwich instead of the physician-ordered pureed diet. The care plan was not updated to reflect the diet change, and the dietary staff was not informed. The CNA, aware of the pureed diet order, was instructed by the nurse to assist the resident with the sandwich. No staff training or auditing of diet changes occurred following the incident.
The facility failed to maintain the walk-in cooler's temperature below 41°F and ensure its cleanliness. The cooling unit was malfunctioning, with temperatures reaching 60°F, and logs were incomplete since April. Mold-like residue was found on shelves and fan grates, with no cleaning records for May or June. The dietary services policy was not followed, as confirmed by the administrator and DON.
Whirlpool Tub Leak Creates Immediate Jeopardy
Penalty
Summary
The deficiency involved a whirlpool tub in a nursing home that was found to have an active water leak near a 120-volt electrical box within its control panel. This situation was observed during a survey, where standing water was noted on the floor under the electrical wires and piping of the control panel. An electrical cord was also found lying in the standing water, creating a potential hazard. The facility's administrator, director of nursing (DON), and facility manager were unaware of the leak, and the whirlpool tub was still in use for resident bathing at the time of the survey. Interviews with staff revealed that the certified nursing assistant (CNA) responsible for bathing residents had been aware of the leak and had informed the facility manager on several occasions. However, no formal work order had been submitted to document the issue, and the maintenance log did not reflect any recent entries regarding the leak. The CNA mentioned that the tub had been broken since she started in November 2024 and was only fixed in December 2024, after which it was used again. Despite the CNA's verbal reports, the facility manager admitted to possibly forgetting about the issue due to the lack of written documentation. Further observations showed that the control panel doors had been removed due to their tendency to fall off, and a corroded cake pan was found under the PVC piping, indicating a long-standing issue. The tub's metal frame was rusted, and the paint was chipping, suggesting neglect in maintenance. The facility's failure to address the leak and ensure the safety of the whirlpool tub led to the identification of an immediate jeopardy situation, as the conditions posed a risk of electric shock to residents and staff.
Failure to Follow Dietician-Approved Menu
Penalty
Summary
The provider failed to meet the nutritional needs of residents by not following the dietician-approved menu. During an observation of the kitchen, it was noted that the lunch served did not include coleslaw as specified in the menu. The dietary manager was unaware of the missing item and had not checked if the meals served matched the approved menu. The cook did not inform the dietary manager about the missing coleslaw and did not substitute it with another item of similar nutritional value. The registered dietician confirmed that the residents were underserved one serving of vegetables due to the absence of coleslaw. Interviews revealed that the dietary manager expected the cook to report any unavailable menu items, but there was no policy in place for menu changes. The cook was unaware of the nutritional requirements and did not take action to address the missing item. The administrator acknowledged that the kitchen staff had been trained by a previous dietary manager and was unaware of the menu discrepancy. As a result, the residents did not receive the full nutritional requirement for the meal served.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The provider failed to adhere to food labeling and storage policies, resulting in multiple instances of improperly labeled and expired food items in the facility's kitchen. Observations revealed unlabeled sandwiches, expired lemon juice, Italian dressing, sour cream, cheese, and milk, as well as rotting tomatoes in the walk-in cooler. Additionally, cereal was stored in salad dressing containers without proper dating, and expired honey and apple cider vinegar were found on a shelf above a food preparation table. These deficiencies were noted during a series of observations conducted over several days. Interviews with kitchen staff, including a cook and dietary aides, highlighted a lack of awareness and responsibility for checking expiration dates. The dietary manager admitted to not having a regular schedule or designated staff member to inspect food products and dates, leading to expired items remaining in storage. The administrator expressed ongoing frustrations with the kitchen and food service, noting that the previous dietary manager had not followed directions and had trained the current staff. The facility's food storage policy requires all containers to be labeled and dated, with specific guidelines for expiration, which were not followed in these instances.
Inadequate Infection Control Practices for Residents with MRSA and Indwelling Catheters
Penalty
Summary
The provider failed to ensure appropriate infection control policies were followed for a resident with a methicillin-resistant Staphylococcus aureus (MRSA) infection and two residents with indwelling catheters. For the resident with MRSA, there was a lack of enhanced barrier precautions (EBP) such as gloves and gowns during contact care. Interviews revealed that staff were not consistently using the required personal protective equipment (PPE) when assisting the resident with dressing, transferring, or bathing. The infection preventionist had only recently initiated EBP for residents requiring it, and there was no signage indicating the need for EBP in the resident's room. For the two residents with indwelling catheters, the facility failed to ensure proper use of PPE. Observations showed that staff were only using gloves and not gowns when providing care. One resident's room lacked signage indicating EBP, and there was no PPE readily available outside the room. Interviews with staff indicated a lack of awareness and understanding of the EBP policy, with some staff expressing confusion about when to use gowns. The facility's enhanced barrier precaution policy indicated that EBP should be used for residents with infections or colonization with multi-drug-resistant organisms (MDROs) and those with wounds or indwelling medical devices. Despite this policy, the care plans for the residents did not reflect the need for EBP, and staff were not consistently following the guidelines. The director of nursing expected staff to follow the EBP policy, but observations and interviews revealed inconsistencies in its implementation.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The provider failed to implement prescribed and care-planned preventative pressure injury interventions for a resident who developed pressure ulcers on both heels. The resident, who was legally blind and had moderate cognitive impairment, was at risk for developing pressure ulcers as indicated by her Braden assessment score. Despite having doctor's orders and a care plan that required the use of Prevalon boots at all times to prevent pressure ulcers, observations revealed that the resident was frequently without these boots. On multiple occasions, the resident was found in her recliner, wheelchair, and bed without the prescribed Prevalon boots, which were instead found on her bed, recliner, and walker. Interviews with staff, including CNAs and an RN, confirmed that the resident was not consistently wearing the Prevalon boots as required. The CNAs admitted to forgetting to put the boots on the resident after transfers and during care activities, despite being aware of the resident's pressure sores. The RN acknowledged that while she was supposed to document the presence of the boots in the treatment administration record, she did not always verify their use after the resident was laid down for naps. The director of nursing emphasized the expectation for staff to follow doctor's orders and care plans, which was not adhered to in this case.
Failure to Update Resident's Care Plan with Dietary Needs
Penalty
Summary
The provider failed to ensure that the care plan for a resident reflected the current individualized dietary needs. The resident, who had Alzheimer's disease and a nutrition and metabolic disease, experienced a decline in cognition, mobility, and chewing/swallowing abilities. Despite a speech therapy evaluation recommending a change to a pureed diet, the resident was given a peanut butter and jelly sandwich, which was not consistent with the updated dietary needs. The care plan did not reflect the physician-ordered change to a pureed diet and still indicated that the kitchen should serve meats cut up, including sandwiches/burgers. The director of nursing revealed that care plans should be updated immediately following an order change or a change in the resident's status. However, the dietary manager did not update the resident's care plan following the physician-ordered diet change. The facility's care plan policy states that care plans should be revised as information about the resident's condition changes, but this was not adhered to in this case.
Failure to Update Resident's Care Plan with Current Diet Order
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected the current individualized diet plan ordered by the resident's physician. The resident, who had severe cognitive impairment and a recent decline in chewing and swallowing abilities, was ordered a pureed diet by the physician. However, the care plan did not reflect this change and instead indicated that the resident should be served meats cut up, including sandwiches. As a result, the resident was fed a peanut butter and jelly sandwich by a CNA, despite the CNA being aware of the pureed diet order. The CNA was instructed by the nurse on duty to assist the resident with eating the sandwich, as the resident had not eaten much for three days prior. The facility's process for updating dietary changes involved speech therapy evaluations, notifying the administrator, and receiving new dietary orders from the doctor. However, the dietary staff was not notified of the resident's diet changes, and the registered nurse was unaware of the incident. Additionally, no education or staff training had been completed since the incident, and no documented auditing regarding residents' diets or diet changes had been conducted. The facility's policies on diet consistency and pureed foods were not followed, as the dietary department was responsible for making consistency modifications, and no diet order changes were to be made without a written order approved by the physician.
Failure to Maintain Safe Temperature and Cleanliness in Walk-In Cooler
Penalty
Summary
The provider failed to maintain the temperature and cleanliness of the walk-in cooler, as observed on June 10, 2024. The cooling unit was not functioning properly, with the air blowing warm and the thermometer reading 60 degrees Fahrenheit, well above the acceptable range of 35 to 40 degrees Fahrenheit. The cooling fins were covered with ice, preventing proper air circulation. Temperature logs were incomplete, with no records from April 13, 2024, to June 10, 2024, and the policy for checking temperatures had been altered without proper documentation. The individual responsible for monitoring temperatures had not been fulfilling their duties. Additionally, the walk-in cooler was found to be unclean, with mold-like residue on 25% of the shelves and fan grates. The provider's cleaning records were outdated, with the last documented cleaning list from April 2024, and no records for May or June 2024. The dietary services sanitization policy required regular cleaning and maintenance, but there was no evidence of compliance. Interviews with the administrator and director of nursing confirmed the unsafe temperature conditions and lack of cleanliness in the cooler.
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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 Wilmot
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Browns Valley Health Center | 12.7 mi | ★★★★★ | 7 | 1 |
| St William's Care Center | 17.3 mi | ★★★★★ | 10 | 0 |
| Avantara Milbank | 17.6 mi | ★★★★★ | 12 | 0 |
| Tekakwitha Living Center | 19.9 mi | ★★★★★ | 15 | 0 |
| Fairway View Neighborhoods | 21.4 mi | ★★★★★ | 1 | 1 |
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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.