Inspection Report Summary
The most recent inspection on October 31, 2025, identified deficiencies related to failure to notify a resident’s physician of a significant change in condition and medication errors involving blood pressure medication. Earlier inspections showed a pattern of issues including incomplete care plans, medication management problems, food safety and sanitation concerns, and staffing deficiencies such as employing an unlicensed social worker. Complaint investigations substantiated failures in timely notification to families and the Ombudsman, with one immediate jeopardy status that was later removed after corrective actions. Enforcement actions such as disciplinary measures and staff training were noted, but fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges in communication and care planning, with some corrective steps taken but recurring themes persisting over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 31, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify a resident's physician of a significant change in the resident's physical status and medication errors.
Complaint Details
The complaint investigation focused on Resident #1, who experienced a significant change in condition that was not reported to the physician, and a medication error involving administration of Losartan potassium outside of prescribed blood pressure parameters. The facility was found to have failed in notifying the physician and family members appropriately, resulting in an Immediate Jeopardy status that was later removed after corrective actions.
Findings
The facility failed to notify the physician of Resident #1's change in condition involving passing large amounts of watery fluids through his ileostomy and failed to report a medication error where blood pressure medication was administered outside prescribed parameters. These failures placed residents at risk of delayed medical intervention, decline in health, serious injury, or death.
Deficiencies (2)
Failed to immediately notify the resident's physician of a significant change in the resident's physical status.
Failed to ensure residents were free from significant medication errors, including administering blood pressure medication outside ordered parameters and failure to notify physician.
Report Facts
Residents reviewed for rights: 4
Residents reviewed for medication errors: 5
Blood pressure medication dose: 25
Blood pressure parameters: 120
Blood pressure parameters: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse who administered medication outside parameters and failed to notify physician. | |
| LVN C | Licensed Vocational Nurse | Documented finding Resident #1 unresponsive and initiated CPR. |
| Physician B | Physician | Physician not notified of resident's change in condition or medication error. |
| Director of Nursing | DON | Involved in corrective action and monitoring. |
| Director of Nurses in Training | DIT | Involved in corrective action and monitoring. |
Inspection Report
Annual Inspection
Capacity: 123
Deficiencies: 4
Date: Jul 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including medication management, care planning, food service safety, and staffing.
Findings
The facility was found deficient in several areas including failure to discontinue unnecessary psychotropic medications after 14 days without documented rationale, failure to develop comprehensive care plans including advance directive information for some residents, improper food handling and sanitation practices in the kitchen, and failure to employ a full-time qualified social worker despite having a capacity over 120 beds.
Deficiencies (4)
Failure to discontinue PRN psychotropic medications (Alprazolam, Xanax, Lorazepam) after 14 days or document rationale for continued use for 3 residents.
Failure to develop and implement comprehensive person-centered care plans including advance directive information for 4 residents.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper hand washing and sanitation by kitchen staff.
Failure to employ a qualified full-time social worker in a facility with more than 120 beds.
Report Facts
Residents reviewed for unnecessary medications: 18
Residents affected by psychotropic medication deficiency: 3
Residents reviewed for comprehensive care plans: 18
Residents affected by care plan deficiency: 4
Facility licensed capacity: 123
Inspection Report
Deficiencies: 3
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication storage, social services staffing, and quality assurance processes at Wisteria Place nursing home.
Findings
The facility was found deficient in developing comprehensive care plans reflecting residents' advanced directives, maintaining medication storage free of expired products, ensuring a licensed social worker was on staff as per plan of correction, and implementing effective quality assessment and assurance activities. These deficiencies posed risks of care not aligned with resident preferences, delayed wound healing, unmet psychosocial needs, and inadequate quality improvement oversight.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, including advanced directive preferences for Resident #37.
Failed to remove expired box of collagen dated 08/2023 from treatment cart.
Failed to ensure the quality assessment and assurance committee developed and implemented appropriate plans of action to correct deficiency of having a full time licensed Social Worker on staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding advanced directive care plan and expired medication findings |
| ADMN | Administrator | Interviewed regarding advanced directive policy, expired medication, and QAPI findings |
| LVN A | Licensed Vocational Nurse | Observed expired collagen on treatment cart and interviewed about medication storage |
| RN B | Registered Nurse | Interviewed about DNR binder usage |
| LVN C | Licensed Vocational Nurse | Interviewed about admission nurse responsibilities for DNR binder |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication storage, and quality assurance processes at Wisteria Place nursing home.
Findings
The facility was found deficient in developing comprehensive care plans that include residents' advanced directives, maintaining up-to-date DNR information in nurse station binders, removing expired treatment products from medication carts, and ensuring the Quality Assessment and Assurance Committee (QAPI) effectively implements corrective actions including staffing a licensed social worker.
Deficiencies (3)
Failed to ensure Resident #37's advanced directive preference was included in care plan or stored in DNR binder at nurses' station.
Failed to remove expired box of collagen dated 08/2023 from treatment cart.
Failed to ensure the QAPI committee developed and implemented appropriate plans of action to correct deficiency of having a full time licensed social worker on staff.
Report Facts
Residents reviewed for advance directives: 18
Treatment carts reviewed: 1
Expired collagen product date: 202308
Plan of Correction completion date: May 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Observed expired collagen on treatment cart and interviewed about medication storage. | |
| DON | Director of Nursing | Interviewed regarding care plan deficiencies and medication storage expectations. |
| ADMN | Administrator | Interviewed regarding QAPI plan, social worker staffing, and policy compliance. |
| RN B | Interviewed about DNR binder usage and nursing station procedures. | |
| LVN C | Interviewed about admission nurse responsibilities for DNR binder. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely notification to the resident, resident representative, and Ombudsman before transfer or discharge, including appeal rights.
Complaint Details
The complaint investigation found that the facility did not send required transfer or discharge notices to the Ombudsman as required, with no 30-day discharge notices received since 3/21/2022 and no transfer/discharge reports since 6/7/2023. The social worker was unaware of the requirement to notify the Ombudsman of all transfers and discharges.
Findings
The facility failed to send a written notice of transfer or discharge and the reasons for the transfer or discharge to the Office of the State Long-Term Care Ombudsman for one resident discharged on 7/14/23. This failure could place residents at risk of being discharged without access to advocacy services and appeal processes. Interviews revealed lack of awareness about notification requirements among staff.
Deficiencies (1)
Failure to provide timely notification to the resident, resident representative, and Ombudsman before transfer or discharge, including appeal rights.
Report Facts
Residents affected: 1
Discharge date: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADMIN | Stated the social worker should handle all discharges and documentation including Ombudsman notifications | |
| SW | Social worker interviewed who was unaware of the requirement to notify the Ombudsman of all transfers and discharges |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Wisteria Place nursing home.
Findings
No health deficiencies were found during the inspection, indicating compliance with applicable standards.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify a resident's family or legal representative when a significant change in condition requiring hospitalization occurred.
Complaint Details
The complaint investigation found that Resident #1 was sent to the hospital on a Monday morning but the family was not notified until the following day, more than 24 hours later. The Infection Control RN who made the decision to send the resident to the hospital failed to notify the family immediately due to distractions and oversight. The Director of Nursing confirmed the failure and took disciplinary action against the nurse. The family expressed upset over the delayed notification.
Findings
The facility failed to notify Resident #1's family or Power of Attorney within 24 hours after the resident was admitted to the hospital for serious medical complications. This failure posed a risk to all residents for not having timely family notification during significant changes in condition. Disciplinary action was taken against the responsible nurse, and staff in-service training was initiated to address the issue.
Deficiencies (1)
Failure to immediately notify resident's family/representative(s) when a significant change in condition requiring hospitalization occurred.
Report Facts
Residents affected: 3
Dialysis schedule: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Control RN | Nurse who made the decision to send Resident #1 to the hospital and failed to notify family immediately | |
| DON | Director of Nursing | Aware of the failure to notify family and took disciplinary action and initiated staff in-service training |
Inspection Report
Routine
Capacity: 123
Deficiencies: 6
Date: Apr 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, nutrition, food safety, social worker qualifications, and infection control at the nursing home.
Findings
The facility was found deficient in maintaining a safe environment free of hazards, proper medication storage and supervision, adherence to menu plans, food safety and hygiene practices, hiring a qualified social worker, and implementing infection prevention and control protocols.
Deficiencies (6)
Failed to keep cleaning agents out of reach of residents, placing them at risk of accidental ingestion.
Medication cart #1 was unlocked when unattended and respiratory treatments were left unsecured at resident bedside.
Residents did not receive a fresh baked roll or approved alternative during lunch meal as per menu.
Food items in the kitchen refrigerator were improperly sealed, labeled, and some were past expiration dates; staff failed to perform proper hand hygiene.
Hired social worker was not licensed as required for a facility with more than 120 beds.
Facility staff failed to wear facemasks properly and failed to perform hand hygiene prior to donning sterile gloves for PICC line dressing change.
Report Facts
Facility licensed bed capacity: 123
Medication cart unlocked incident: 1
Expired food items: 3
Social worker hire date: Sep 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Charge Nurse | Named in finding for failing to wear mask properly and leaving medication cart unlocked |
| DON | Director of Nursing | Provided statements regarding medication cart locking and infection control practices |
| ADM | Administrator | Provided statements regarding facility policies, social worker qualifications, and infection control |
| RN-E | Registered Nurse | Named in finding for failing to perform hand hygiene before donning sterile gloves for PICC line dressing change |
| Social Worker | Social Worker | Hired social worker without required license |
Inspection Report
Routine
Capacity: 123
Deficiencies: 6
Date: Apr 12, 2023
Visit Reason
Routine inspection of Wisteria Place nursing home to assess compliance with health and safety regulations including accident hazards, medication storage, nutrition, food safety, social worker qualifications, and infection control.
Findings
The facility was found to have multiple deficiencies including unsafe storage of cleaning agents, unlocked medication carts, unsecured respiratory medications, failure to follow menu plans, improper food storage and hygiene practices, unlicensed social worker employed, and lapses in infection prevention and control practices such as improper mask use and inadequate hand hygiene during sterile procedures.
Deficiencies (6)
Failed to keep cleaning agents out of reach of residents, placing them at risk of accidental ingestion.
Medication cart #1 was unlocked when unattended and respiratory treatments left unsecured at resident bedside.
Menu was not followed; residents did not receive a fresh baked roll or approved alternative during lunch meal.
Food was improperly stored, unlabeled, past expiration date, and staff failed to perform proper hand hygiene.
Facility hired a full-time social worker who was not licensed by the Texas State Board of Social Worker Examiners.
Facility staff failed to wear facemasks properly and failed to perform hand hygiene prior to donning sterile gloves for PICC line dressing change.
Report Facts
Facility licensed capacity: 123
Medication cart unlocked: 1
Expired food items: 3
Resident #25 BIMS score: 4
Resident #21 BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Charge Nurse | Failed to lock medication cart and did not wear mask properly during shift |
| RN-E | Registered Nurse | Failed to perform hand hygiene prior to donning sterile gloves for PICC line dressing change |
| Social Worker | Social Worker | Employed without required license, holds Bachelor of Arts in Human Services |
| ADM | Administrator | Provided interviews regarding deficiencies and facility policies |
| DON | Director of Nursing | Provided interviews regarding medication cart locking and infection control practices |
| DM | Dietary Manager | Provided interviews regarding menu adherence and food safety |
| LVN-D | Licensed Vocational Nurse | Provided interview regarding medication storage at bedside policies |
Viewing
Loading inspection reports...
