Wisteria Gardens

Inspectors wroteBased 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 in the front pocket of his shirt. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure staff followed infection prevention and hand hygiene practices during catheter care for one (1) of three (3) residents observed for infection control. Resident #32.

Inspectors wroteBased 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.

Inspectors wroteBased 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 . Resident #43 A record review of the admission Record revealed the facility admitted Resident #43 on 01/20/2025 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). [...]

Inspectors wroteBased on facility policy review, record reviews, and staff interviews, the facility failed to correctly code a Minimum Data Set (MDS) discharge assessment for one (1) of fourteen (14) sampled residents reviewed for assessment accuracy. Resident #48 Findings Include: Record review of the facility's, Accurate Completion of Social Determinates of Health -Minimum Data Set (MDS) Policy dated October 2023 revealed It is the policy of this facility to ensure that . data are accurately captured within the MDS per the current Resident Assessment Instrument (RAI) Guidelines .The MDS Coordinator will ensure that these data elements are carried out timely and coded accurately . Record review of the Discharge Minimum Data Set (MDS) for Resident #48 revealed an admission date of 11/13/24. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure medications were safely and securely stored for one (1) of four (4) residents observed for medication administration. Resident #43 Findings Include: A record review of the facility's Medication Labeling and Storage revised 2/2023, revealed, .The facility stores all medication and biologicals in locked compartments .Medication Storage .2. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner . On 02/19/2025 at 9:45 AM, during an observation with Licensed Practical Nurse (LPN) #3, Albuterol Sulfate HFA Inhalation Aerosol Solution was observed on Resident #43's nightstand table in a clear plastic bag. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency. Specifically, the facility was cited for failing to label, date, and discard expired items stored in the refrigerator, freezer, and dry storage room during an annual recertification survey on 10/19/23 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of six (6) deficiencies cited. F812 Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record and facility policy review, the facility failed to follow infection prevention guidelines in two (2) of (10) observed care procedures as evidenced by staff did not don (put on) appropriate personal protective equipment (PPE), including gowns, per Enhanced Barrier Precautions (EBP) during Percutaneous Endoscopic Gastrostomy (PEG) tube and Foley catheter care for Resident #43 and Resident #251. Findings Include: A record review of the facility's policy Enhanced Barrier Precautions dated April 2024 revealed .Policy Interpretation and Implementation: 1. EBP will be used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug resistant organism (MDROs) to staff . [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review the facility failed to manage a resident's pain by not administering medication per physician orders for one (1) of three (3) residents reviewed for pain.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to post the daily staffing hours for public viewing (4) of four (4) days reviewed for staff posting.