Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Wisteria Place during CMS and state inspections, most recent first.
A resident with COPD and continuous oxygen orders was observed wearing a nasal cannula with an oxygen concentrator running, but no oxygen in use sign was posted outside her room. Staff stated the sign likely was not moved after the resident changed rooms, and the DON confirmed the facility had no policy for oxygen administration or oxygen sign posting.
Incomplete Oxygen and Respiratory Documentation: A resident with OSA, pulmonary HTN, and severe cognitive impairment had an order for PRN high-flow O2 to keep O2 sat above 90%, but the MAR did not show oxygen administration and the chart lacked O2 saturation documentation. Progress notes recorded repeated use of 3 to 6 LPM via NC, but did not include the saturation levels or the reason for giving O2.
A resident receiving PRN hydrocodone-acetaminophen for post–knee replacement pain had a physician order for dosing every four hours as needed for moderate to severe pain, but the MAR contained no documentation of hydrocodone administration over multiple consecutive days while the narcotic sign-out sheet showed doses given with signatures and pill counts. The resident reported not missing any pain medication, and an RN described routinely assessing pain and administering hydrocodone per order, documenting only on the narcotics log. The DON acknowledged the blank MAR and suggested staff were not properly documenting in the electronic system, contrary to facility policy requiring immediate, complete documentation of controlled medication administration.
A resident with multiple comorbidities experienced a significant change in condition, including increased watery output from an ileostomy and low blood pressure, but the nurse did not notify the physician or document the change. The nurse also administered antihypertensive medication outside of prescribed parameters and failed to report the medication error. The resident was later found unresponsive and pronounced dead. Facility policy required immediate physician notification for such changes and errors, but this was not done.
A nurse administered Losartan Potassium to a resident with severe cognitive impairment and multiple comorbidities, despite the resident's blood pressure being below the physician-ordered threshold. The nurse did not notify the DON or physician of the medication error, and the facility's policy for reporting such errors was not followed. The resident subsequently exhibited changes in condition, and vital signs indicated low blood pressure.
PRN psychotropic orders for three residents were left active without a 14-day stop date or documented rationale for continuation. One resident had Alprazolam ordered for anxiety, another had Xanax ordered, and a third had Lorazepam ordered; MAR review showed doses were given for each. The DON-IT stated PRN psych meds should have had a 14-day stop date and that the issue was overlooked.
Advance directive information was missing from the care plans for four residents. Two residents had Full Code orders with AED/CPR, and two residents had DNR orders, including OOH-DNR documentation, but none of the care plans included those code status details. Interviews showed one resident wanted CPR, another wanted staff to do everything to keep her alive, and another said his advance directive was not discussed during the care plan meeting. The MDS Coordinator, Operations Manager, and DON stated advance directives were not required to be care planned.
Improper Hand Hygiene and Food Handling in Kitchen: Dietary staff were observed handling cooked food, utensils, and serving items without proper hand hygiene or sanitation. An employee used oven mitts and a thermometer between food items without washing hands or changing gloves, an Assistant Dietary Supervisor handled silverware by the eating surfaces and touched her nose while continuing to work, and dietary aides returned from outside, handled food and serving utensils with unwashed hands, and served food while touching plate eating surfaces and food with their hands.
Failure to employ a full-time social worker in a facility with 123 licensed beds. Review of the employee list showed no social worker on staff, and the OM stated the prior social worker had left, the position had been posted, and no licensed SW applications were received until later. The OM stated the facility expected to have a full-time licensed social worker and did not have a social services policy.
A facility failed to include a resident's DNR status in both the care plan and the DNR binder, despite having a signed DNR form. The resident, with a history of stroke and cardiac issues, was admitted without her advanced directive preferences being accessible to staff. Interviews revealed that the facility did not follow its policy for managing advanced directives, leading to a potential risk of not honoring the resident's wishes in an emergency.
An expired box of collagen sheets was found on a treatment cart during a survey at an LTC facility. LVN A acknowledged the oversight, despite having checked the cart earlier. The DON and ADMN stated that treatment products should be used before expiration, with regular audits and monitoring in place. The facility's policy requires immediate removal of outdated medications.
The facility did not ensure a full-time licensed social worker was on staff to meet residents' social needs, despite a plan of correction. The Social Services Manager was not licensed, and a candidate declined the position due to relocation issues. The Administrator believed the plan was followed, but the QAPI plan's emphasis on quality improvement was not effectively implemented, risking unmet social services for residents.
Missing Oxygen In Use Sign for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who required continuous oxygen therapy. Resident #5 was an [AGE]-year-old female admitted with COPD, had a BIMS score of 15 indicating she was cognitively intact, and had physician orders for oxygen via nasal cannula at 1-4 LPM continuously to keep saturation greater than 92%. Her care plan also directed staff to give oxygen therapy as ordered. On 05/19/2026, the resident was observed sitting in her room wearing a nasal cannula with an oxygen concentrator delivering oxygen at 2 LPM. During the same observation, there was no oxygen in use sign posted outside the resident’s room. The resident stated she had been on oxygen since admission and had recently changed rooms. LVN C stated the sign should have been outside the room and may not have been moved when the resident changed rooms, and the DON stated the sign must have not been moved with her after the room change. The DON, LVN C, CNA A, and the ADMN all stated that oxygen in use signs were expected to be posted for residents receiving oxygen, and the DON stated the facility did not have a policy for oxygen administration or oxygen in use signs.
Incomplete Oxygen and Respiratory Documentation
Penalty
Summary
The facility failed to ensure medical records were maintained in a complete and accurately documented manner for Resident #6. Resident #6 was an [AGE]-year-old female admitted and readmitted to the facility with diagnoses including OSA and pulmonary hypertension, and her quarterly MDS reflected a BIMS score of 05 indicating severe cognitive impairment. Her comprehensive care plan identified altered respiratory status and difficulty breathing related to OSA and pulmonary hypertension, with interventions to provide oxygen as ordered and to monitor and document abnormal breathing patterns and changes in orientation, restlessness, anxiety, and air hunger. Record review showed an electronic physician order for high-flow oxygen at 6-10 LPM via nasal cannula PRN for SOB to maintain O2 saturation above 90%, but the May 2026 MAR did not show evidence that oxygen was administered or that oxygen saturation levels were checked. Progress notes documented multiple instances in which Resident #6 was on high-flow oxygen at 3 to 6 LPM via nasal cannula, but the notes did not include oxygen saturation levels or the reason for administering oxygen. The report also states that incidents, accidents, or changes in residents' condition should be documented and that treatments shall be documented in the clinical record.
Incomplete MAR Documentation for PRN Hydrocodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN hydrocodone-acetaminophen for post–knee replacement pain. The resident, an older female with unilateral primary osteoarthritis of the left knee, aftercare following left knee joint replacement, and an anxiety disorder, had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain (4–10). Review of the Medication Administration Record (MAR) showed missing sign-out entries for this hydrocodone from 2/21/26 through 2/27/26, despite the resident’s report that she had not missed any doses and that staff consistently provided the medication when needed. The facility’s narcotic sign-out sheet for February 2026, however, contained dates, signatures, and pill counts for hydrocodone administration on those same dates. During interviews, the DON acknowledged that the MAR for this resident was blank for the relevant period and stated she did not know why, suggesting there might be an issue with the electronic tracking system or that staff were not properly “clicking out” the medication in the system. RN A reported that she worked with the resident on pain control every day she worked, assessed the resident’s pain each morning, and administered hydrocodone whenever the resident requested it in accordance with the physician’s order, documenting only on the narcotics sign-out log. Direct observation on 2/27/26 showed RN A assessing the resident’s pain at level 6, pulling and administering the correct hydrocodone dose, and signing the narcotics document, with no infection control issues noted. The facility’s policy on controlled medications required the licensed nurse to immediately enter the date, time, amount administered, and signature on the accountability record after administration, but the MAR entries for hydrocodone were not completed for the specified dates.
Failure to Notify Physician of Change in Condition and Medication Error
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical status. The resident, an elderly male with a history of Ogilvie Syndrome, ileostomy, hypokalemia, atherosclerotic heart disease, and congestive heart failure, began passing large amounts of watery fluids through his ileostomy, which was a new symptom for him. Despite this change, the nurse on duty did not contact the physician, nor was there documentation of physician notification in the resident's chart. The nurse also administered losartan potassium outside of the prescribed blood pressure parameters and did not report this medication error to the physician. The resident's family member noticed the change in the resident's condition, including altered breathing, pallor, and weakness, and brought these concerns to the nurse's attention. The nurse took the resident's vital signs, which showed low blood pressure, but reassured the family member that the situation was not critical and stated that labs would be obtained in the morning. The family member also reported that the resident had similar symptoms previously when he was dehydrated and had low potassium, but no immediate action was taken by the nurse to notify the physician or escalate care. Later, the resident was found unresponsive and subsequently pronounced dead. The physician confirmed that she was not notified of the resident's change in condition or the medication error, and stated that she would have ordered immediate labs and considered sending the resident to the emergency room had she been informed. Facility policy required immediate notification of the physician for significant changes in condition and for medication errors, but these procedures were not followed in this case.
Blood Pressure Medication Administered Outside Ordered Parameters and Not Reported
Penalty
Summary
A registered nurse administered Losartan Potassium 25 mg to a male resident with severe cognitive impairment, despite the physician's order to hold the medication if the systolic blood pressure (SBP) was less than 120 or diastolic blood pressure (DBP) was less than 70. At the time of administration, the resident's blood pressure was 110/76, which was outside the ordered parameters. The nurse did not notify the Director of Nursing (DON) or the physician about the medication error as required by facility policy. Following the administration, the resident's family member observed changes in the resident's condition, including altered breathing, pallor, and increased weakness, and requested that the nurse check his vital signs. The nurse found the resident's blood pressure to be 98/50. Subsequent interviews confirmed that neither the DON nor the physician was informed of the medication error, and the facility's policy requiring immediate reporting of such errors was not followed. The resident had multiple comorbidities, including a history of heart disease, hypokalemia, and congestive heart failure.
PRN psychotropic orders lacked required 14-day stop dates or documented rationale
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints not required to treat their medical symptoms because PRN anti-anxiety medications were not discontinued after 14 days or supported by a documented rationale for continued use. Resident #7 had diagnoses including anxiety, delusional disorders, and psychosis, and had an order for Alprazolam 0.5 mg every 6 hours as needed for anxiety starting 03/06/2025 with no stop date. Resident #8 had diagnoses including a fractured leg, liver disease, and heart failure, and had an order for Xanax 0.25 mg every 12 hours as needed for anxiety starting 07/09/2025 with no stop date. Resident #77 had diagnoses including high blood pressure, urinary tract infection, and lung disease, and had an order for Lorazepam 0.5 mg every 8 hours as needed for anxiety starting 07/03/2025 with no stop date. Record review showed that Resident #7’s July 2025 MAR documented one dose of Alprazolam administered on 07/10/2025, Resident #8’s July 2025 MAR documented doses of Xanax administered on 07/12/2025 and 07/13/2025, and Resident #77’s July 2025 MAR documented doses of Lorazepam administered on 07/19/2025 and 07/27/2025. For each resident, the physician progress notes contained no evidence of a documented rationale to keep the PRN medication ordered beyond 14 days. The care plans for these residents included anti-anxiety medication use and interventions to give the ordered medication and monitor/document side effects and effectiveness. During interview, the DON-IT stated that all PRN psych medications should have had a 14-day stop date and that after 14 days the resident needed to be reevaluated for the need to continue the medication. She stated it was her and the nurse manager’s responsibility to monitor orders when entered to ensure stop dates were included, and that the failure occurred because it was overlooked. The facility policy titled Psychotropic Drug Use stated that PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of the medication.
Advance Directive Information Missing From Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 4 residents by not including advance directive information in their care plans. Resident #68 had diagnoses of metabolic encephalopathy and acute kidney failure, a BIMS score of 10 indicating moderate impairment, and a standing order for Full Code with AED and CPR, but the care plan did not include the resident’s desire to be resuscitated in the event of sudden cardiac arrest. During interview, the resident stated she wanted staff to do everything they could to keep her alive and did not recall discussing that decision during a care plan meeting. Resident #07 had diagnoses including unspecified atrial fibrillation, cognitive communication deficit, and delusional disorders, and had a standing order for Full Code with AED and CPR. Her quarterly MDS did not calculate a BIMS score, and the section indicating whether the Brief Interview for Mental Status should be conducted was left blank. Her care plan did not include advance directive information or her desire to be resuscitated. During interview, she stated she wanted CPR because she did not want to die and was unable to state whether the choice was discussed at her care plan meeting. Resident #65 had Parkinson’s disease and dementia with psychotic disturbance, was rarely or never understood, and had a standing order for DNR along with an out-of-hospital DNR order that was in place before admission. Resident #30 had heart failure and unspecified dementia, had no BIMS score calculated, and also had a standing order for DNR with an out-of-hospital DNR order. Neither resident’s care plan included the presence of the formal DNR. Resident #65 was unable to respond to interview questions, and Resident #30 stated his advance directive was not discussed during his care plan meeting, though he said he discussed his signed DNR when he first came into the facility.
Improper Hand Hygiene and Food Handling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation, a dietary employee wore gloves while removing cooked chicken, spinach, and mashed potatoes from the oven, used oven mitts between tasks, and placed a thermometer into each food item without washing hands or changing gloves before or after handling the mitts. The employee then returned the pans to the oven and continued food handling without hand hygiene between tasks. An Assistant Dietary Supervisor was observed handling clean silverware by the eating surfaces rather than by the handles. While wearing gloves, she picked up spoons by the eating end, knives by the blade end, and forks by the tines, rolled them in napkins, and placed them in a bin. During the same observation, she rubbed the side of her nose with her right hand and continued handling silverware and napkins without changing gloves or washing hands. A Dietary Aide exited the kitchen, entered an outside storage refrigerator/freezer unit, retrieved dessert, and returned to the kitchen without washing hands. He then handled a pan with unwashed hands, stacked cups, and used a serving scoop with bare hands to portion dessert into bowls. Another Dietary Aide was observed rubbing the back of her neck, then later serving mashed potatoes and spinach without washing hands or wearing gloves, while touching the eating surfaces of plates with her thumb and brushing food with her thumb and fingers. She also wiped her hand on her pant leg after spinach juice contacted her fingers. Facility interviews confirmed the staff knew these actions were improper and could cause cross contamination, and the Dietary Manager and Operations Manager stated the actions did not meet expectations.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis in a building with a licensed capacity of 123 resident beds. Review of the facility-provided employee list dated 07/28/2025 showed no social worker on staff. During an interview on 07/30/2025 at 2:10 PM, the OM stated the facility did not currently have a social worker and that the previous social worker’s last day was 06/25/2025. The OM stated the position had been posted on 06/11/2025, but no applications from licensed social workers were received until 07/29/2025. The OM also stated the salary had been raised and a sign-on bonus added, that the expectation was to have a full-time licensed social worker, and that the facility did not have a policy for social services.
Failure to Include DNR Status in Care Plan and Binder
Penalty
Summary
The facility failed to develop a comprehensive care plan that included the advanced directive preferences for a resident, identified as Resident #37. The resident, a female with a history of cerebral infarction, cardiac pacemaker, and metabolic encephalopathy, was admitted to the facility without her DNR status being included in her care plan or the DNR binder at the nurses' station. Despite having a signed DNR form, the facility did not ensure that this critical information was accessible to direct care staff, as the DNR binder for the resident's unit did not contain her advanced directive wishes. Interviews with facility staff, including the DON, RN, LVN, and ADMN, revealed a lack of adherence to the facility's policy regarding the management of advanced directives. The admission nurse was responsible for placing the resident's DNR status in the binder, but this was not done. The DON and ADMN acknowledged the oversight and the potential risk it posed, as the absence of this information could lead to the resident's advanced directive not being followed in an emergency. The facility's policy required that the social worker or designee keep the DNR binders updated, but this was not effectively implemented for Resident #37.
Expired Medication Found on Treatment Cart
Penalty
Summary
The facility failed to ensure that expired medication and treatment products were not present on the treatment cart, as observed during a survey. Specifically, an expired box of collagen sheets, which are used to promote wound healing, was found on the treatment cart. LVN A, who was setting up wound treatment supplies, acknowledged the presence of the expired product and admitted that it should not have been left on the cart. Despite having checked the cart earlier in the day, LVN A did not notice the expired dressing at that time. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the facility's expectation was for treatment products to be used before their expiration date. The DON stated that treatment nurses are responsible for auditing their carts weekly, with nursing management also conducting monitoring. The ADMN emphasized that it was the treatment nurse's responsibility to ensure products were not expired, and that nursing management should double-check. The facility's policy mandates the immediate removal and disposal of outdated medications. The failure to adhere to these procedures could have resulted in decreased potency of the treatment, potentially affecting the healing process.
Failure to Implement Plan for Licensed Social Worker
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to address the deficiency of not having a full-time licensed social worker on staff to meet the social needs of all residents. Despite the facility's plan of correction submitted in response to a previous survey, which included contracting a licensed social worker, the Social Services Manager was not a licensed social worker. The Administrator acknowledged that the Social Services Manager held a Bachelor of Arts degree in Human Services and that a licensed social worker candidate had declined the position due to relocation issues. The Administrator stated that the Plan of Correction was discussed at every monthly QAPI meeting, and she believed the actions outlined in the plan were followed. However, the facility's QAPI plan emphasized the importance of using QAPI to manage operations and improve quality of care, which was not effectively implemented in this case. The failure to have a licensed social worker could place all residents at risk for unmet social services and psychosocial needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 134 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowcreek Rehab And Nursing | 2.5 mi | ★★★★★ | 9 | 0 |
| Windcrest Health & Rehabilitation | 2.7 mi | ★★★★★ | 11 | 0 |
| Wesley Court Health Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Mesa Springs Healthcare Center | 3.4 mi | ★★★★★ | 15 | 0 |
| Brightpointe At Lytle Lake | 3.9 mi | ★★★★★ | 10 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wisteria Place.
100% money-back within 48 hours.
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.