Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wisteria Gardens during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, with expired, improperly stored, and unlabeled food items found in the kitchen. Observations revealed expired lime juice, unlabeled beef tips and diced ham, and freezer-burned chicken gizzards. The CDM and staff acknowledged the issues, despite regular in-service training on food safety. The Administrator noted ongoing spot checks but recognized the need for improved monitoring.
The facility exceeded the acceptable medication error rate, reaching 10.34% during a medication pass observation. An LPN failed to administer a prescribed inhaler to a resident with COPD and incorrectly dosed eye drops for another resident with glaucoma. The errors were confirmed through staff interviews and record reviews.
A facility failed to accurately code the MDS discharge assessment for a resident. The MDS indicated discharge to an acute hospital, while progress notes showed the resident was discharged home with Hospice. The error was confirmed by the MDS Coordinator and attributed to a misinterpretation of notes by the DON.
A facility failed to securely store medications, as an Albuterol inhaler was found on a resident's nightstand without a physician's order permitting bedside storage. The LPN and DON confirmed that medications should be locked unless otherwise ordered, to prevent potential overdose. The resident had COPD and an active order for the inhaler as needed for shortness of breath.
The facility's QAPI committee failed to sustain corrective actions for a previously cited deficiency related to food storage and labeling. During a survey, the facility was again cited for failing to label, date, and discard expired items in the kitchen, indicating insufficient monitoring and oversight. Despite random checks by the Administrator, issues with expired, freezer-burned, improperly stored, and unlabeled foods were observed.
Two residents received care without proper PPE, as staff failed to don gowns during PEG tube and Foley catheter procedures, despite EBP signage. Both residents had severely impaired cognition and required careful infection control. Staff acknowledged the oversight, and the facility's policy mandates PPE use to prevent MDRO spread.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by the presence of expired, improperly stored, and unlabeled food items in the kitchen. During an observation, a gallon bottle of lime juice with a cloudy film and a manufacturer's date was found in the walk-in refrigerator, along with containers of beef tips and diced ham that lacked labels and dates. Additionally, a package of roast beef slices did not have a facility thawed on or use by date, and a bag of chopped cabbage was past its best if used by date. In the freezer, several bags of chicken gizzards were found without labels and showed signs of freezer burn. The Certified Dietary Manager (CDM) acknowledged these issues and stated that it is the responsibility of all kitchen staff to check for and discard expired foods, as well as to label and date food items. Interviews with the kitchen staff revealed that all members are responsible for labeling, dating, and monitoring food items for expiration. The staff receive in-service training on food safety, with varying frequencies reported by different staff members. The Administrator acknowledged the deficiencies and mentioned that the facility owner conducts spot checks in the kitchen every two weeks. Despite these measures, the facility's practices did not prevent the occurrence of expired and improperly stored food items, indicating a lapse in adherence to the facility's policy on handling perishable foods.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34% during a medication pass observation. This deficiency was identified through the observation of three medication errors out of 29 opportunities, affecting two residents. One resident, admitted with Chronic Obstructive Pulmonary Disease (COPD), did not receive their prescribed Breo Ellipta inhaler because the LPN could not locate the medication in the cart or the resident's room. The medication was not administered, and the LPN confirmed the failure to administer the medication during interviews. Another resident, admitted with Unspecified Glaucoma, received an incorrect dosage of Timolol Maleate Ophthalmic Solution. The LPN administered two drops in each eye instead of the prescribed one drop per eye. The LPN acknowledged the error during an interview, and the DON confirmed that the medication should have been administered according to the physician's order. These errors highlight the facility's failure to adhere to safe medication administration practices as outlined in their policy.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) discharge assessment for one of the sampled residents, identified as Resident #48. The facility's policy mandates that data be accurately captured within the MDS according to the current Resident Assessment Instrument (RAI) Guidelines. However, a review of the Discharge MDS for Resident #48 showed a discrepancy. The MDS indicated that the resident was discharged to an acute hospital, while the facility's progress notes revealed that the resident was actually discharged home with Hospice. This error was confirmed by the MDS Coordinator, who acknowledged the mistake during an interview. The Director of Nursing also confirmed the error, attributing it to a misinterpretation of the progress notes, which led to the incorrect coding of the discharge destination.
Medication Storage Deficiency Observed
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for a resident observed during medication administration. During an observation, an Albuterol Sulfate HFA Inhalation Aerosol Solution was found on the nightstand of a resident, stored in a clear plastic bag. This was contrary to the facility's policy, which mandates that all medications and biologicals be stored in locked compartments. The Licensed Practical Nurse (LPN) confirmed that medications should not be left at the bedside unless there is a physician's order permitting it, acknowledging that leaving medications accessible could lead to potential overdose. The Director of Nursing (DON) reiterated that medications should not be left at the bedside without a physician's order, as this could result in residents using more than the prescribed amount. The resident involved had been admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had an active physician order for the Albuterol inhaler to be used as needed for shortness of breath or wheezing. The DON confirmed that the expectation was for nursing staff to ensure medications are securely stored according to facility policy.
QAPI Committee Fails to Sustain Corrective Actions for Food Storage Deficiency
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent the recurrence of a previously cited deficiency related to food storage and labeling. During an annual recertification survey, the facility was cited for failing to label, date, and discard expired items stored in the refrigerator, freezer, and dry storage room. This deficiency was noted again during the current survey, indicating that the QAPI committee did not maintain ongoing monitoring and oversight to prevent recurrence. The facility's policy on QAPI outlines that the committee should help departments develop and implement plans of correction, track progress, and advise on necessary policy changes, but these actions were not effectively sustained. During the current survey, observations revealed that the facility failed to store food and maintain sanitary practices according to professional standards for food safety. This included issues with expired foods, freezer-burned foods, improperly stored foods, and unlabeled and undated foods during two kitchen observations. The Administrator acknowledged awareness of the previous citation and stated that random checks of the kitchen were performed several times a month, but these measures were insufficient to prevent the recurrence of the deficiency.
Failure to Follow Infection Prevention Guidelines
Penalty
Summary
The facility failed to adhere to infection prevention guidelines during care procedures for two residents. In the first instance, a Licensed Practical Nurse (LPN) was observed providing care to a resident's Percutaneous Endoscopic Gastrostomy (PEG) tube site without donning a gown, despite signage indicating the need for Enhanced Barrier Precautions (EBP). The LPN acknowledged the oversight and confirmed that the resident's condition required the use of personal protective equipment (PPE) to prevent infection transmission. The resident had a history of cerebral infarction and severely impaired cognition, necessitating careful adherence to infection control protocols. In the second instance, a Certified Nurse Aide (CNA) provided Foley catheter care to another resident without wearing a gown, contrary to the EBP signage posted on the resident's door. The CNA admitted to not following the required precautions, which are crucial for residents with invasive lines and tubes. This resident also had severely impaired cognition and was diagnosed with chronic kidney disease. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff are expected to comply with PPE requirements to prevent the spread of multidrug-resistant organisms (MDROs) as per facility policy and CDC guidelines.
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| Brandon Community Care Center | 0.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.