Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
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 Place during CMS and state inspections, most recent first.
A resident receiving PRN hydrocodone-acetaminophen for post–knee replacement pain had a physician order for dosing every four hours as needed for moderate to severe pain, but the MAR contained no documentation of hydrocodone administration over multiple consecutive days while the narcotic sign-out sheet showed doses given with signatures and pill counts. The resident reported not missing any pain medication, and an RN described routinely assessing pain and administering hydrocodone per order, documenting only on the narcotics log. The DON acknowledged the blank MAR and suggested staff were not properly documenting in the electronic system, contrary to facility policy requiring immediate, complete documentation of controlled medication administration.
A resident with multiple comorbidities experienced a significant change in condition, including increased watery output from an ileostomy and low blood pressure, but the nurse did not notify the physician or document the change. The nurse also administered antihypertensive medication outside of prescribed parameters and failed to report the medication error. The resident was later found unresponsive and pronounced dead. Facility policy required immediate physician notification for such changes and errors, but this was not done.
A nurse administered Losartan Potassium to a resident with severe cognitive impairment and multiple comorbidities, despite the resident's blood pressure being below the physician-ordered threshold. The nurse did not notify the DON or physician of the medication error, and the facility's policy for reporting such errors was not followed. The resident subsequently exhibited changes in condition, and vital signs indicated low blood pressure.
A facility failed to include a resident's DNR status in both the care plan and the DNR binder, despite having a signed DNR form. The resident, with a history of stroke and cardiac issues, was admitted without her advanced directive preferences being accessible to staff. Interviews revealed that the facility did not follow its policy for managing advanced directives, leading to a potential risk of not honoring the resident's wishes in an emergency.
An expired box of collagen sheets was found on a treatment cart during a survey at an LTC facility. LVN A acknowledged the oversight, despite having checked the cart earlier. The DON and ADMN stated that treatment products should be used before expiration, with regular audits and monitoring in place. The facility's policy requires immediate removal of outdated medications.
The facility did not ensure a full-time licensed social worker was on staff to meet residents' social needs, despite a plan of correction. The Social Services Manager was not licensed, and a candidate declined the position due to relocation issues. The Administrator believed the plan was followed, but the QAPI plan's emphasis on quality improvement was not effectively implemented, risking unmet social services for residents.
Incomplete MAR Documentation for PRN Hydrocodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN hydrocodone-acetaminophen for post–knee replacement pain. The resident, an older female with unilateral primary osteoarthritis of the left knee, aftercare following left knee joint replacement, and an anxiety disorder, had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain (4–10). Review of the Medication Administration Record (MAR) showed missing sign-out entries for this hydrocodone from 2/21/26 through 2/27/26, despite the resident’s report that she had not missed any doses and that staff consistently provided the medication when needed. The facility’s narcotic sign-out sheet for February 2026, however, contained dates, signatures, and pill counts for hydrocodone administration on those same dates. During interviews, the DON acknowledged that the MAR for this resident was blank for the relevant period and stated she did not know why, suggesting there might be an issue with the electronic tracking system or that staff were not properly “clicking out” the medication in the system. RN A reported that she worked with the resident on pain control every day she worked, assessed the resident’s pain each morning, and administered hydrocodone whenever the resident requested it in accordance with the physician’s order, documenting only on the narcotics sign-out log. Direct observation on 2/27/26 showed RN A assessing the resident’s pain at level 6, pulling and administering the correct hydrocodone dose, and signing the narcotics document, with no infection control issues noted. The facility’s policy on controlled medications required the licensed nurse to immediately enter the date, time, amount administered, and signature on the accountability record after administration, but the MAR entries for hydrocodone were not completed for the specified dates.
Failure to Notify Physician of Change in Condition and Medication Error
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical status. The resident, an elderly male with a history of Ogilvie Syndrome, ileostomy, hypokalemia, atherosclerotic heart disease, and congestive heart failure, began passing large amounts of watery fluids through his ileostomy, which was a new symptom for him. Despite this change, the nurse on duty did not contact the physician, nor was there documentation of physician notification in the resident's chart. The nurse also administered losartan potassium outside of the prescribed blood pressure parameters and did not report this medication error to the physician. The resident's family member noticed the change in the resident's condition, including altered breathing, pallor, and weakness, and brought these concerns to the nurse's attention. The nurse took the resident's vital signs, which showed low blood pressure, but reassured the family member that the situation was not critical and stated that labs would be obtained in the morning. The family member also reported that the resident had similar symptoms previously when he was dehydrated and had low potassium, but no immediate action was taken by the nurse to notify the physician or escalate care. Later, the resident was found unresponsive and subsequently pronounced dead. The physician confirmed that she was not notified of the resident's change in condition or the medication error, and stated that she would have ordered immediate labs and considered sending the resident to the emergency room had she been informed. Facility policy required immediate notification of the physician for significant changes in condition and for medication errors, but these procedures were not followed in this case.
Blood Pressure Medication Administered Outside Ordered Parameters and Not Reported
Penalty
Summary
A registered nurse administered Losartan Potassium 25 mg to a male resident with severe cognitive impairment, despite the physician's order to hold the medication if the systolic blood pressure (SBP) was less than 120 or diastolic blood pressure (DBP) was less than 70. At the time of administration, the resident's blood pressure was 110/76, which was outside the ordered parameters. The nurse did not notify the Director of Nursing (DON) or the physician about the medication error as required by facility policy. Following the administration, the resident's family member observed changes in the resident's condition, including altered breathing, pallor, and increased weakness, and requested that the nurse check his vital signs. The nurse found the resident's blood pressure to be 98/50. Subsequent interviews confirmed that neither the DON nor the physician was informed of the medication error, and the facility's policy requiring immediate reporting of such errors was not followed. The resident had multiple comorbidities, including a history of heart disease, hypokalemia, and congestive heart failure.
Failure to Include DNR Status in Care Plan and Binder
Penalty
Summary
The facility failed to develop a comprehensive care plan that included the advanced directive preferences for a resident, identified as Resident #37. The resident, a female with a history of cerebral infarction, cardiac pacemaker, and metabolic encephalopathy, was admitted to the facility without her DNR status being included in her care plan or the DNR binder at the nurses' station. Despite having a signed DNR form, the facility did not ensure that this critical information was accessible to direct care staff, as the DNR binder for the resident's unit did not contain her advanced directive wishes. Interviews with facility staff, including the DON, RN, LVN, and ADMN, revealed a lack of adherence to the facility's policy regarding the management of advanced directives. The admission nurse was responsible for placing the resident's DNR status in the binder, but this was not done. The DON and ADMN acknowledged the oversight and the potential risk it posed, as the absence of this information could lead to the resident's advanced directive not being followed in an emergency. The facility's policy required that the social worker or designee keep the DNR binders updated, but this was not effectively implemented for Resident #37.
Expired Medication Found on Treatment Cart
Penalty
Summary
The facility failed to ensure that expired medication and treatment products were not present on the treatment cart, as observed during a survey. Specifically, an expired box of collagen sheets, which are used to promote wound healing, was found on the treatment cart. LVN A, who was setting up wound treatment supplies, acknowledged the presence of the expired product and admitted that it should not have been left on the cart. Despite having checked the cart earlier in the day, LVN A did not notice the expired dressing at that time. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the facility's expectation was for treatment products to be used before their expiration date. The DON stated that treatment nurses are responsible for auditing their carts weekly, with nursing management also conducting monitoring. The ADMN emphasized that it was the treatment nurse's responsibility to ensure products were not expired, and that nursing management should double-check. The facility's policy mandates the immediate removal and disposal of outdated medications. The failure to adhere to these procedures could have resulted in decreased potency of the treatment, potentially affecting the healing process.
Failure to Implement Plan for Licensed Social Worker
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to address the deficiency of not having a full-time licensed social worker on staff to meet the social needs of all residents. Despite the facility's plan of correction submitted in response to a previous survey, which included contracting a licensed social worker, the Social Services Manager was not a licensed social worker. The Administrator acknowledged that the Social Services Manager held a Bachelor of Arts degree in Human Services and that a licensed social worker candidate had declined the position due to relocation issues. The Administrator stated that the Plan of Correction was discussed at every monthly QAPI meeting, and she believed the actions outlined in the plan were followed. However, the facility's QAPI plan emphasized the importance of using QAPI to manage operations and improve quality of care, which was not effectively implemented in this case. The failure to have a licensed social worker could place all residents at risk for unmet social services and psychosocial needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowcreek Rehab And Nursing | 2.5 mi | — | 1 | 0 |
| Windcrest Health & Rehabilitation | 2.7 mi | — | 0 | 0 |
| Wesley Court Health Center | 2.8 mi | — | 0 | 0 |
| Mesa Springs Healthcare Center | 3.4 mi | — | 15 | 0 |
| Brightpointe At Lytle Lake | 3.9 mi | — | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wisteria Place.
100% money-back within 48 hours.
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.