Wisteria Gardens

In the surveyor’s words

From the most serious findings on record at Wisteria Gardens, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 20, 2025

  Based on observation, staff interview, and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to expired foods, freezer burned foods, improperly stored foods, and unlabeled and undated foods for two (2) of (2) kitchen observations. Findings include: A review of the facility's policy, Handling of Perishable Foods, Revision Date: [DATE] revealed, Policy: To ensure foods are protected from contamination or spoilage. Any growth of organisms is prevented by proper storage and temperatures .Policy .10. All items .will be properly labeled with the Item, Initials, Date and use by date .12. […]

• No harm, potential for more than minimal, widespreadF812Oct 19, 2023

  Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and the dry storage room were dated, labeled, and discarded by the expiration date for one (1) of three (3) dietary observations. This has the potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen) dated 2016, revealed, . Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration . An observation of the kitchen on [DATE] at 9:15 AM, with the Dietary Manager (DM), revealed several expired food items. […]

• No harm, potential for more than minimal, patternF759Feb 20, 2025

  Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (5%) as evidenced by three (3) errors were observed out of 29 medication administration opportunities. This affected two (2) of four (4) residents observed during medication pass, resulting in a medication error rate of 10.34%. (Resident #43 and Resident #154) Findings Include: A record review of facility's policy Medication and Treatment Orders, undated, revealed, .Orders for medications and treatments will be consistent with principles of safe and effective order writing . […]

• No harm, potential for more than minimal, patternF563Sep 10, 2021

  Based on observation, staff and resident representative interview, record review, Resident Council Committee review and facility policy review the facility failed to honor the resident's rights for visitation with family for six (6) of 6 resident/resident representative interviews. Resident #138's Resident Representative and Resident #6, #8, #21, #87 and #140. Findings Include: Record review of the facility visitation policy titled, Visitation during COVID-19 Public Health Emergency ([NAME]), updated March 2021, revealed, wisteria gardens follows current guidelines and recommendations for the prevention and control of COVID-19. […]

• No harm, potential for more than minimal, isolatedF689Mar 11, 2026

  Based on observation, interview, record review, and facility statment review the facility failed to ensure a safe smoking program and failed to assess a resident for safe smoking practices for one (1) of three (3) residents reviewed for accident hazards. Resident #17.FindingsRecord review of a typed statement on facility letterhead dated 3/11/26 and signed by the Director of Nursing (DON) revealed, (Name of Facility) does not have a policy requiring the completion of a smoking assessment for Residents who use tobacco products.On 03/09/26 at 11:41 AM, Resident #17 was observed eating lunch in his room with cigarettes visible in the front pocket of his shirt.On 03/11/26 at 8:18 AM, Resident #17 was observed traveling in a wheelchair down the hallway near the nurse's station with cigarettes… […]