Wisteria Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Oct 31, 2025

  Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for 1 of 4 resident (Resident #1) reviewed for resident rights. The facility failed to notify the physician on [DATE] of a resident's change in condition of Resident #1's passing large amounts of watery fluids through his ileostomy and the resident expired on [DATE]. Resident #1's death certificate listed cause of death as Coronary Artery Thrombosis (blood clot). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. […]

• No harm, potential for more than minimal, patternF605Jul 30, 2025

  Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #7, Resident #8, and Resident #77) of 18 residents reviewed for unnecessary medications. The facility failed to ensure Resident #7's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #8's PRN Xanax (Alprazolam) (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. […]

• No harm, potential for more than minimal, patternF656Jul 30, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 18 residents (Resident #68, Resident #07, Resident #65, Resident #30) reviewed for comprehensive person-centered care plans. […]

• No harm, potential for more than minimal, patternF812Jul 30, 2025

  Based on observation, interview, and record review, 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 for kitchen sanitation. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling and serving food. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 07/28/2025 at 11:05 a.m., [NAME] E, who was wearing gloves, put a pair of oven mitts on and removed a pan of oven cooked chicken from the oven. [NAME] E removed the oven mitts and picked up and placed a thermometer into a piece of chicken. […]

• No harm, potential for more than minimal, patternF803Apr 12, 2023

  Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 of 1 observed lunch meal on 04/10/2023. The facility failed to ensure residents received a fresh baked role or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Observation and review of posted daily facility menu for Monday 04/10/06/2023 revealed: Lunch: Sweet/Sour Meatballs, Steamed Rice, Seas Green Beans, Roll/Marg, Iced Brownie, Beverage and Whole Milk. Observation of the meal on 04/10/2023 at 11:30 AM revealed residents were served Sweet/Sour Meatballs, Steamed Rice, Green Beans, and an Iced Brownie. […]