Wisteria Place

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 (Resident #5) residents observed for oxygen management. The facility failed to post an oxygen in use sign indicating Resident #5 received oxygen. This failure could place residents at risk of receiving incorrect or inadequate oxygen support; decline in health; and at risk of fire hazards. Findings Included:Record review of Resident #5's electronic face sheet dated 05/19/2026 reflected an [AGE] year-old female with an admission date of 03/17/2026 and diagnosis including COPD (chronic respiratory disease that obstructs the airways and interferes with breathing). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 of 6 (Resident #6) residents reviewed for accurate records. The facility failed to include oxygen administration on Resident #6's MAR. The facility failed to document oxygen saturation levels in the vital signs when oxygen utilized to keep saturation levels greater than 90% for Resident #6. These failures could place residents of an accurate depiction of care in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy and completeness. The facility failed to completely and accurately document Hydrocodone was being given to Resident #1 from 2/21/26 to 2/27/26. This deficient practice could put residents at risk of not receiving needed services.

Inspectors wroteBased 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. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors in that: RN A gave Resident #1's blood pressure medication Losartan Potassium 25 mg needed for hypertension, outside of the ordered parameters. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication by receiving too much or not enough. Findings Included: Record review of a Comprehensive assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] and expired on [DATE]. He had a primary diagnosis of [NAME] Syndrome (paralysis of colon - colon acts like it is blocked but nothing is blocking it). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The facility failed to develop a comprehensive care plan for Resident #68, Resident #07, Resident #65, and Resident #30 that included advance directive information. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis. The facility failed to ensure the facility had a full-time social worker between the time of 6/25/2025 to 07/30/2025. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the development of comprehensive care plan that meets allof a residnt's need for 1 of 18 residents (Resident #37) reviewed for advance directives. The facility failed to ensure that Resident #37's advanced directive preference was included in care plan or stored in DNR binder at the nurses' station. The facility failed to have the advanced directive in the binder and failed to implement their policies for implementing advance directives This failure could place residents at risk of receiving treatments that go against their personal preferences and does not allow them to make an informed decision about their care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure no expired medication/treatment products were not on 1 of 1 Treatment cart reviewed for medication storage. The facility failed to remove expired box of collagen dated 08/2023 from treatment cart. This failure could result in delayed healing of wound.

Inspectors wroteBased on interviews, record reviews the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct deficiency of having a full time Social Worker on staff for Residents social needs for all resident. The facility failed to ensure the QAPI committee, which included the Administrator, DON, Medical Director, had followed the facility's plan of correction dated 04/12/2023. This failure could place all residents at risk for unmet social services and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed . The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not past expiration date. The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat from the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to maintain an environment that remained free of accident hazards. The facility failed to keep cleaning agents out of the reach of residents. This failure placed residents at risk of accidental ingestion of chemicals.

Inspectors wroteBased observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts, and unsecured respiratory medications at resident bedside, reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended by RN-A. The facility failed to ensure Resident #25srespiratory treatments were not left at bedside and used unsupervised . This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions.

Inspectors wroteBased on observations interviews and record reviews, the facility failed to maintain an infection prevention and control program for 2 (RN-A, RN-E) of 8 staff and 1(Resident #21) of 5 residents reviewed for infection control. Facility staff failed to wear facemask properly. Facility staff failed to perform hand hygiene prior to donning surgical gloves for a sterile dressing change of Resident #21's PICC line. These failures placed residents at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hired Social Worker had the required qualifications for 1 of 1 facility reviewed for social worker qualifications. The social worker hired on September 30, 2021, as a full-time social worker was not licensed by the Texas State Board of Social Worker Examiners. This failure could place all residents at risk for unmet social services and psychosocial needs.