Wilber Care Center

Licensure Reference Number 175 NA 12-006.09(I)Based on record review and interviews, the facility failed to implement interventions to provide a safe environment when residents are identified as at risk for elopement (when an individual with dementia leaves a safe or supervised area without authorization or knowledge) for Resident 1, Resident 2, and Resident 3. This affected 3 of 3 residents sampled for elopement. The facility census was 33.Findings are:A.A record review of the facility's Elopement-Missing Resident policy last revised 03/01/2024 and in place at the time of Resident 1's elopement revealed that preventative measures were:-maintenance supervisor to check all doors weekly to assure the Wanderguard doors were functioning.-identify residents at risk for elopement and put a Wanderguard device on them.-at 10:00 PM the charge nurse or designated person would ensure all alarmed doors were working properly and that all exit doors were locked.B.A record review of Resident 1's Continuity of Care Document (CCD) created 06-10-2026 revealed the facility admitted the resident on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.02(H)Based on record reviews and interviews, the facility failed to submit an investigative report for Resident 1 within the required time frame. This affected 1 of 1 residents sample for reporting. The facility census was 33.Findings are:A record review of Resident 1's Continuity of Care Document created 06-10-2026 revealed the facility admitted the resident on 04/22/2026 with diagnoses of Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills), and vascular dementia (a decline in thinking and reasoning skills caused by restricted or blocked blood flow to the brain).A record review of Resident 1's Resident Progress Notes revealed a note from 05/25/2026 at 5:53 PM that revealed the resident had eloped (when an individual with dementia leaves a safe or supervised area without authorization or knowledge) and that the resident's Wanderguard had not set off the door alarm on exit or entry to the building.A review of an undated preliminary report provided by the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 12-006.18(B) Based on observation, record review and interview, the facility failed to wear the required Personal Protective Equipment (PPE-personal protective equipment-special equipment, including gloves, gown, masks and eye protection, worn to prevent exposure to hazards such as infectious materials), place soiled linen in a linen bag, ensure supplies were placed on a clean surface and throw a soiled glove in the trash can all during wound care for Resident 1, and failed to perform peri-care in a manner to prevent cross-contamination, and complete hand hygiene when changing gloves and after assisting with cares for Residents 11 and 12. This affected 3 out of 3 sampled residents. The facility census was 30. Findings are: A. Record review of the facility's Hand Hygiene policy, last revised 02/25 revealed staff are to wash hands vigorously, lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds, or longer under a moderate stream…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

License reference number NAC 12-007.03(K)Based on observation, and interview, the facility failed to provide a safe walkway in the hallway for ambulatory residents. This affected 1 out of 2 sampled residents but had the potential to affect all ambulatory residents. The facility census was 30.Findings are: A.Record review on 05/19/2026 at 2:58 PM revealed Resident 32 had an admission date of 02/07/2025. Record review of Resident 32's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 05/07/2026 revealed that Resident 32 had moderately impaired cognition and wandered daily. The MDS also revealed Resident 32 had vascular dementia, Alzheimer's Disease, and anxiety. Record review of Resident 32's care plan revealed that Resident 32 wandered without purpose. The facility had placed interventions on the care plan stating Resident 32 does wander and staff are to redirect Resident 32, and staff were to avoid over stimulation for Resident 32. Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report suspicions of abuse to the state agency within the required timeframe. This affected 2 residents, (Resident 1 and Resident 3). The facility census was 32. Findings are: A. A review of the facility's Investigation Report Abuse-Physical sent to the state agency's email on 02/20/2025 at 2:54 PM revealed that on 02/19/2025 at 4:30 PM a bruise was discovered on Resident 3's right back/hip and on 02/20/2025 at 1:59 PM the bruise was reported to Adult Protective Services (APS). A review of an undated summary written by the Director of Nursing (DON) revealed that Resident 3 had been unable to explain how the bruise happened. Further review revealed that the DON did not observe the area until 02/20/2025 at 1:00 PM, and the incident was not reported to APS until 02/20/2025 at 1:59 PM. An interview on 07/02/2025 at 2:31 PM with the DON confirmed that the report was called to APS more than two hours after the injury was discovered. B. A review of the facility's Investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to complete annual performance evaluations for 4 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37. Findings are: A record review of the employee file for Medication Aide (MA) D with a hire date of 09/19/2009 revealed a Staff Evaluation Report (SER) dated 09/19/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA E with a hire date of 04/16/2022 revealed there was no SER available. A record review of the employee file for MA F with a hire date of 09/10/1998 revealed an SER dated 09/19/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA J with a hire date of 05/18/2021 revealed an SER dated 08/17/2023 and signed by both the evaluator and the employee. A record review of the employee file for MA K with a hire date of 01/26/2022 revealed an SER dated 01/23/2024. This was signed by the evaluator only, and there was no documentation of discussion of review with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to provide the required annual in-service training for 3 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37. Findings are: A review of the undated User Learning document provided for Medication Aide (MA) D revealed no documentation of any training completed after 10/08/2022. A review of the undated User Learning document provided for MA E revealed some training done in 2024. The Administrator (ADM) had written how many hours the individual courses were, and the total hours provided added up to 6.25 hours. A review of the undated User Learning document provided for MA F revealed no documentation of any training completed after 05/04/2023. An interview on 01/21/2025 at 3:08 PM with the ADM confirmed that MA D had no documentation of training more recent than 2022 and MA F had no documentation of training more recent than 2023. The ADM further confirmed that the hours written on MA E's User Learning record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.(18)(D) Based on observations, record reviews and interviews, the facility failed to ensure hand hygiene (using an alcohol-based hand rub (ABHR) or washing hands with soap and water) was completed in a manner to prevent cross-contamination during peri-care (washing the genitals and anal area) for Resident 8 and Resident 25 and during wound care for Resident 12. This affected 3 of 4 residents observed for peri-care and wound care. The facility census was 37. A record review of the facility's Handwashing/Hand Hygiene policy dated 12/05/2023 revealed that hand hygiene should be completed in the following situations: Before and after direct contact with residents; Before handling clean or soiled dressings; Before moving from a contaminated body site to a clean body site during resident care; After contact with blood or body fluids; After handling used dressings; and After removing gloves. The policy further revealed that glove use did not replace hand hygiene and that the procedure for washing hands with soap and water included rubbing hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding use of an anti-anxiety medication for Resident 8 and for use of a Bilevel Positive Airway (BiPAP-a machine used to deliver positive airway to a person's airway to prevent it from closing during sleep) for Resident 18. This affected 2 (Resident 8 and Resident 18) of 16 residents sampled for MDS accuracy. The facility census was 37. Findings are: A. A review of Resident 8's Continuity of Care Document (CCD) created 01/16/2025 revealed an admission date of 05/22/2023 and a diagnosis of anxiety. A review of Resident 8's Physician Order Report from 12/16/2024 to 01/16/2025 revealed an order for lorazepam (an anti-anxiety medication) 0.5 milligrams once a day by mouth for anxiety. A review of Resident 8's Quarterly MDS dated [DATE] revealed that Section N-Medications was not marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to complete a trauma based assessment for 1 (Resident 7) of 5 sampled residents. The facility census was 37. Findings are: A record review of Resident 7's Significant change Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 9/20/2024 revealed an admission date of 5/29/2024, a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 1 which suggests severe cognitive impairment, and diagnosis of Anxiety, Depression and frequent pain. A record review of Resident 7's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 12/16/2024 revealed no history of trauma. In an interview on 1/15/2025 at 2:59 PM with Resident 7's representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to notify a resident representative and provider regarding a change in condition for 1 (Resident 37) of 1 sampled residents. The facility census was 35. Findings are: A record review of Residents 37's Face Sheet dated [DATE] revealed Resident 37 had the following diagnoses: hypertension, Pneumonia, Flu, COVID-19, arthritis, cystitis, Generalized Weakness, Peripheral vascular disease, Mixed hyperlipidemia, Hypokalemia, depressive disorder, and Anxiety disorder. A record review of the form titled Wilber Care Center Documentation Guidelines, last updated 10/23 revealed: - document in progress notes any cognitive, medical changes that effect a residents daily functioning. This will be documented every shift until resolved and/or addressed by a physician. Record review of Resident 37's Progress Notes revealed on [DATE] at 11:30 PM the facility staff reported to the nurse that Resident 37 was having an emesis.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D7b Based interview, and record review; the facility failed to conduct a thorough investigation to determine the root-cause of falls and failed to develop and implement effective interventions to minimize and/or prevent falls for 1 (Resident 23) of 1 sampled resident. The facility census was 35. Findings are: Interview on 2/7/24 at 10:38 AM with Resident 23's resident representative (RR) revealed that Resident 23 had a fall two weeks ago and scraped up Resident 23's left arm and elbow. The RR further revealed that Resident 23 walks independently without a walker or cane and is unsteady at times. Observation on 2/7/24 at 11:40 AM revealed Resident 23, with no assistive device, standing next to the window at the nurse's station talking with the staff. Interview on 2/12/24 at 9:38 AM the Medication Aide (MA) revealed that Resident 23 can walk independently and at times Resident 23 is unsteady. MA further revealed that Resident 23 has attempted to assist Resident 23's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 175 NAC 12-006.05(5) Based on record review and interviews, the facility failed to provide a written notice of transfer to Resident 23 and Resident 6 and/or their representatives upon transfer to the emergency room (ER). The facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) of transfer for Resident 23 and Resident 6. This affected 2 of 2 residents sampled for hospitalization. The facility census was 33. Findings are: A. Record review of Resident 23's Electronic Health Record (EHR) revealed the resident was sent to the ER on [DATE] with respiratory complaints and returned to the facility on 3/24/23. Resident 23's EHR revealed Resident 23 was sent back to the ER with a change in responsiveness and a decreased oxygen saturation (an indication of how well the lungs are working) and was admitted to the hospital. An interview on 04/06/23 at 10:48 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

B. An observation on 04/05/23 at 9:00 AM revealed Resident 6's CPAP mask was laying on top of CPAP machine without being covered. An observation on 04/06/23 at 11:25 AM Resident 6's CPAP mask was laying on top of CPAP machine without being covered. Record review of CPAP/BIPAP Cleaning Policy dated 3/7/11 did not mention how to store a CPAP mask to prevent contamination. Interview with the Infection Preventionist (IP) on 4/6/23 at 1:40 PM revealed that the resident's CPAP mask was not being stored in a manner to prevent contamination. Interview with the Director of Nursing (DON) on 04/06/23 at 2:00 PM revealed that the resident's CPAP mask was not being stored in an manner to prevent contaminiation. Based on observation, record review, and interview; the facility failed to put measures in place to prevent cross-contamination (the transfer of disease-causing organisms from one surface to another) by failing to store oxygen cannulas (the part of the tubing that goes into the nostrils) for Resident 25 and a CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.