Wilson Care and Rehab

In the surveyor’s words

From the most serious findings on record at Wilson Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF609Nov 7, 2022

  The facility identified a census of 39 residents with three reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported witnessed abuse. On 10/26/22 between 10:00 PM and 11:00 PM, Certified Nurse Aide (CNA) M, CNA N, and CNA Q repositioned cognitively impaired Resident (R) 1. R1 swatted at CNA M. CNA Q then slapped R1's hand and told him no. CNA M witnessed CNA Q slap R1, but did not report to the charge nurse or facility administrative staff. Later in her shift, CNA M texted the information to CNA P. CNA P identified the incident as reportable and encouraged CNA M to report the incident, however CNA P then delayed reporting the abuse until 02:30 PM on 10/27/22. […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2025

  The facility identified a census of 34 residents, with 12 included in the sample. Based on observation, record review, and interview, the facility failed to ensure nursing staff donned (put on) the appropriate required Enhance Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) before providing direct cares to Resident (R) 5 and ensure staff did not set R5's catheter bag (medical device that collects urine) directly on the resident's floor. The facility failed to ensure nursing staff donned the required EBP and performed hand hygiene prior to and during the wound dressing change for R15. […]

• No harm, potential for more than minimal, widespreadF812Feb 5, 2024

  The facility had a census of 34 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to ensure appropriate sanitation of dishware used for preparing, and serving residents' meals, and failed to prepare, store, distribute, and serve food under sanitary conditions for the 34 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness. Findings included: - On 01/30/24 at 08:40 AM, observation revealed Dietary Staff (DS) CC operated the dishwasher and attempted to test the dishwasher rinse for chemical sanitation. The wash and rinse temperatures were 105 degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, widespreadF851Feb 5, 2024

  The facility had a census of 34 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 the PBJ report for Quarter 2 indicated the facility had excessively low weekend staff. […]

• No harm, potential for more than minimal, widespreadF880Sep 26, 2022

  The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to monitor laundry temperatures to ensure proper disinfection and cleaning of soiled linens and clothing. This deficient practice placed residents at risk for infection and illness. Findings included: - On 09/21/22 at 12:00 PM, observation in the facility's laundry rooms revealed Housekeeping V checked the temperature logs for the washing machines. Washer 1 (small one used for bleaching) temperature log for August 2022 lacked documentation on 8/1, 8/9, 8/19, 8/20, 8/21, 8/30, and 8/31. Washer 3 (commercial) August 2022 temperature log lacked documentation of temperatures on 8/1, 8/9, 8/11-24, 8/30, and 8/31. […]