Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wisner Care Center during CMS and state inspections, most recent first.
Dishwasher Temperatures Not Reaching Required Sanitation Level: The facility failed to ensure the dishwasher consistently reached the 120-degree minimum needed for proper sanitation. Logs showed wash and rinse temps were checked multiple times but often did not reach the required level, and the CDM confirmed staff were unsure of the correct temps and had not been educated on them; the dishwasher log also listed an incorrect range of 110 to 120 degrees.
Incomplete informed consent for psychotropic medications: The facility failed to document comprehensive consent before giving psychotropic meds to multiple residents. Consent forms for antipsychotic, antidepressant, and antianxiety meds did not include dose or frequency, symptoms being treated, adverse effects, nonpharmacological interventions, or treatment alternatives. The DON, MDS Coordinator, and RN confirmed the missing information for residents with dementia, depression, anxiety, and behavioral symptoms.
Failure to report a hot liquid spill with injury as suspected abuse/neglect. A resident with Alzheimer disease, severe cognitive impairment, and partial assist with eating was identified as at risk for hot spills. Nursing notes documented fluid-filled blisters on both inner thighs, and the DON confirmed the resident had a hot liquid spill that caused the injuries. The facility had no evidence of an investigation and did not report the event to APS as required.
A resident with Alzheimer disease and severe cognitive impairment was at risk for hot spills and had care plan interventions in place, including a vinyl clothing protector, a meal card alert, and cups filled half full. After a hot liquid spill caused fluid-filled blisters to both inner thighs, the facility did not complete an investigation or report the incident to APS or the State Agency, and the DON confirmed the spill occurred.
Failure to provide toileting and incontinence care: A resident with severe cognitive impairment, Parkinson's disease, and total dependence for ADLs was observed sitting for hours without toileting or incontinence checks. Staff later found the resident heavily soiled with urine and feces, and staff confirmed the resident had not been checked since early morning despite a care plan for regular toileting assistance.
A cognitively intact resident with DM received scheduled Humalog and Lantus, but the record showed repeated Humalog refusals and held doses, with many refusals lacking a documented reason. The chart contained no evidence that the resident was educated about refusing insulin or that the MD was updated about the ongoing refusals; the MDS Coordinator, DON, and Administrator confirmed the facility lacked a policy for insulin refusal and physician notification.
Failure to implement fall prevention interventions for a resident at high risk for falls. The resident had dementia, Parkinson's disease, diabetes, and severe cognitive impairment, with a care plan calling for a pull alarm on the recliner, a Dicem pad on the wheelchair seat, scheduled toileting, and placement in the recliner for supervision. Surveyors observed the resident in a wheelchair and recliner without the required alarm in place, and the wheelchair lacked the non-slip pad. The resident was also found soiled with urine and feces, and the DON confirmed the resident had multiple recent falls.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, as required by their policy. Despite the resident's chronic wounds, staff did not use gowns and gloves during high-contact care activities, and there were no signs or isolation supplies visible. This non-compliance with the EBP policy was observed during toileting care and skin assessments.
Dishwasher Temperatures Not Reaching Required Sanitation Level
Penalty
Summary
The facility failed to ensure the dishwasher was reaching temperatures needed for adequate sanitation of dishes. Review of the facility’s undated policies showed staff were expected to wash and sanitize dishes after each meal and monitor dish machine temperatures throughout the cycle, but the policy did not specify the required water temperatures. An e-mail from the solution specialist confirmed that for the chemical sanitation system, dishwasher temperatures needed to reach a minimum of 120 degrees in accordance with the food code. Review of the facility’s temperature logs for June and July 2026 showed the dishwasher temperatures were checked multiple times daily but were not consistently reaching 120 degrees. In June 2026, wash temperatures were recorded 85 times and reached 120 degrees only 18 times, while rinse temperatures reached 120 degrees 68 times; the log also listed an incorrect temperature range of 110 to 120 degrees. In July 2026, wash temperatures reached 120 degrees 5 times out of 17 checks and rinse temperatures reached 120 degrees 9 times. During interview, the CDM confirmed being unsure of the required wash and rinse temperatures and stated that staff had not been educated on the correct temperatures, and the current dishwasher log range of 110 to 120 degrees was incorrect.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain informed consent and/or comprehensive informed consent for psychotropic medications before administration for Residents 2, 14, 15, 31, and 32. The deficiency involved consent forms that did not document the current dose and/or how often the medications were to be given, and did not include education about the residents’ symptoms, potential effects or adverse effects, nonpharmacological interventions attempted, or treatment alternatives. The cited policy stated that residents were to be informed in advance of the benefits, risks, and alternatives before initiation or increase of a psychotropic medication, and that the facility was to document that this information had been provided. Resident 2 had diagnoses including dementia and depression and was assessed as having severe cognitive impairment, mood symptoms, and behavioral symptoms. The record showed consent forms for Ativan and Seroquel, but the forms did not show how often or at what dosage the medications were to be given, and did not show education about symptoms, adverse effects, or nonpharmacological interventions. The MAR showed continued use of Seroquel 25 mg three times daily and Ativan 2 mg/ml 0.25 ml every 12 hours as needed. The DON confirmed the consents lacked documentation of nonpharmacological interventions, treatment alternatives, symptoms, and medication effects, and did not address dosage or frequency. Resident 15 was cognitively intact and had diagnoses including depression, hypertension, and diabetes, with behaviors including rejection of care and social isolation. The record showed Sertraline was started and later increased, but the consent form for Sertraline did not include the dose or frequency, symptoms being treated, potential side effects, or nonpharmacological interventions. The MDS Coordinator and DON confirmed the consent did not include nonpharmacological interventions, alternative treatment options, side effects, dosage, or frequency, and further confirmed the facility did not obtain consent before administration and did not obtain a new consent when the medication was increased. Similar deficiencies were identified for Residents 14, 31, and 32, whose records showed psychotropic medications including Trazodone, Divalproex Sodium, Duloxetine, Olanzapine, Sertraline, Lorazepam, and Buspar, while the consent forms lacked dosage and frequency information and did not document symptoms, adverse effects, or nonpharmacological interventions. RN-N confirmed these omissions for Resident 32 during interview.
Failure to Report Hot Liquid Spill With Injury as Suspected Abuse/Neglect
Penalty
Summary
The facility failed to timely report a hot liquid spill with injury as suspected abuse or neglect for a resident with Alzheimer disease, severe cognitive impairment, and partial assistance needs with eating. The facility policy stated that suspicion and/or knowledge of abuse would be immediately reported to a charge nurse or department supervisor, investigated by the Administrator or DON, and reported to APS and the State Agency within 5 working days of the alleged or potential abuse. Resident 32’s MDS dated 4/2/26 showed Alzheimer disease, severe cognitive impairment, and partial assist with eating. The resident’s high-risk-for-hot-spills assessment identified the resident as at risk for hot spills. Nursing documentation showed the physician was notified on 1/13/26 regarding blisters, and a facility fax from 1/13/26 at 3:00 AM documented several fluid-filled blisters on both inner thighs. Review of the facility’s reported investigations from 3/4/25 to 7/7/26 found no evidence that the facility completed an investigation for the hot liquid spill that caused the blisters. The DON confirmed in interview that the resident had a hot liquid spill that caused fluid-filled areas to the right and left inner thighs, and the facility did not report the event to APS.
Failure to Investigate and Report Hot Liquid Spill Injury
Penalty
Summary
The facility failed to investigate a hot liquid spill involving a resident with Alzheimer disease and severe cognitive impairment who required partial assistance with eating. The resident was identified as high risk for hot spills, with interventions including a vinyl clothing protector, a meal card alerting staff to the risk, and hot liquid cups filled half full. After the incident, nursing documentation noted blisters on both inner thighs, and a fax documented several fluid-filled blisters on the right and left inner thighs. Review of the facility’s reported investigations showed no evidence that the facility completed an investigation into the hot liquid spill that caused the blisters. The facility also did not report the hot liquid spill to APS or submit the required complete report to the State Agency within 5 working days. The DON confirmed that the resident did have a hot liquid spill that caused the fluid-filled areas to both inner thighs.
Failure to Provide Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide assistance with toileting and incontinence care for a resident who required total staff assistance with activities of daily living. The resident had diagnoses including anemia, coronary artery disease, non-Alzheimer's dementia, Parkinson's disease, depression, PTSD, overactive bladder, and benign prostatic hyperplasia. The MDS indicated severely impaired cognition, dependence for toileting hygiene, dressing, personal hygiene, and transfers, and frequent bowel and bladder incontinence. The care plan identified toileting assistance in the morning, before and after each meal, at bedtime, and as needed, and a bowel and bladder assessment documented frequent incontinence and the need for toileting hygiene assistance. On observation, the resident was awake and seated in a tilt-n-space wheelchair for several hours, including during breakfast and while positioned near the bird aviary. At 10:00 AM, a feces odor was noted from the resident's area. When staff later assisted the resident to the room and stood the resident in a sit-to-stand lift, the resident's slacks and disposable brief were found heavily soiled with urine and feces. Staff stated the resident had not been toileted or checked for incontinence since being assisted out of bed at 6:30 AM. The DON confirmed the resident should be toileted every 2 hours to prevent attempts to self-transfer and reduce fall risk.
Failure to Document Education and Physician Notification for Repeated Insulin Refusals
Penalty
Summary
The facility failed to provide documented evidence of education to a cognitively intact resident regarding repeated refusals of Humalog insulin and failed to document that the physician was updated about those refusals. The resident had diagnoses including depression, hypertension, and diabetes, and the care plan identified the resident as receiving long- and short-acting insulin with a risk for fluctuating blood sugars. The care plan did not include documentation about insulin refusal or interventions for when insulin was refused. Review of the MAR and progress notes showed the resident received 12 of 44 scheduled Humalog doses during the review period, with numerous refusals and several held doses due to low blood sugar readings. Some refusals included no reason documented, while one note recorded the resident stating blood sugars run low all the time and that the resident did not need insulin. Further review found no evidence that the resident was educated about refusing insulin and no evidence that the physician had been updated when Humalog was held or refused. The MDS Coordinator, Administrator, and DON confirmed the facility did not have a policy for insulin administration or for notifying the physician when a resident refuses insulin, and confirmed there was no documentation of resident education.
Failure to Implement Fall Prevention Interventions for a High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident who had been assessed as high risk for falls. The resident had diagnoses including anemia, coronary artery disease, diabetes, non-Alzheimer's dementia, Parkinson's disease, depression, and post-traumatic-stress-disorder, and was assessed as having severe cognitive impairment, requiring substantial to maximal assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's care plan identified fall risk related to Parkinson's disease and diabetic neuropathy and included interventions such as a pull alarm to the recliner, a video monitor, a Dicem non-slip pad on the wheelchair seat, scheduled toileting, and placement in the lobby recliner for increased supervision. Incident reports showed the resident had multiple falls in the preceding months, including falls in the commons area, the resident's room, and the dining room. During observation, the resident was seen seated in a wheelchair near the bird aviary, later in the dining room, and then back near the bird aviary. The resident was observed with a feces odor and soiled clothing, and staff found the resident's incontinence brief heavily soiled with urine and feces. The wheelchair seat did not have the Dicem pad in place. Later, the resident was seated in a recliner near the nurse's station and then in the front commons area, but the pull alarm was observed on a table next to the resident rather than attached to the resident or recliner, and at another time no pull alarm was observed on the resident or recliner. The DON confirmed the resident was high risk for falls, had three falls over the last seven months, and was to have the pull alarm, Dicem pad, scheduled toileting, and recliner placement for supervision.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, as required by their policy. The policy, implemented on 5/17/24, mandates the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices, even if they are not known to be infected with Multi-Drug-Resistant Organisms (MDRO). Observations revealed that there were no signs posted or visible isolation supplies for EBP on multiple occasions, and staff did not wear gowns when entering the resident's room to perform care activities. The resident, identified as having a stage 3 pressure ulcer on the right upper buttock/coccyx, was not provided with the necessary precautions to prevent infection transmission. Despite the chronic nature of the wounds, as confirmed by the skin nurse, the facility did not adhere to its own EBP policy. This lack of implementation was observed during toileting care and skin assessments, where staff failed to use the required personal protective equipment, thereby not following the infection control intervention designed to reduce MDRO transmission.
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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 Wisner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Haven | 6.7 mi | ★★★★★ | 4 | 0 |
| St Joseph's Hillside Villa | 14.5 mi | ★★★★★ | 2 | 0 |
| Stanton Health Center | 17.1 mi | ★★★★★ | 2 | 0 |
| Wayne Countryview Care And Rehabilitation | 18 mi | ★★★★★ | 8 | 0 |
| Wakefield Health Care Center | 19.2 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 October 2026) and official state health department websites.