Wisteria Place

Penalties

• Oct 31, 2025 — Fine ($14,069)

Inspection findings

1. May 20, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected May 21, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected May 21, 2026 · CMS health inspection

2. Mar 4, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Mar 18, 2026 · CMS health inspection

3. Oct 31, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Nov 1, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 1, 2025 · CMS health inspection

4. Jul 30, 2025 Health · 10 findings
   • Not serious Scope/severity E

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Sep 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Sep 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 12, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0850 Administration Deficiencies

     Hire a qualified full-time social worker in a facility with more than 120 beds.

     Corrected Sep 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Aug 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Aug 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Aug 27, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0754 Miscellaneous Deficiencies

     Provide properly sized and located linen or trash receptacles.

     Corrected Aug 27, 2025 · CMS fire safety

5. Jun 26, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 27, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 27, 2024 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Jun 27, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jul 1, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 28, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 28, 2024 · CMS fire safety

6. Nov 1, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Dec 15, 2023 · CMS health inspection

7. Apr 12, 2023 Health · 6 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0850 Administration Deficiencies

     Hire a qualified full-time social worker in a facility with more than 120 beds.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 15, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 01/01/2011
• GILLIS, ERIC — adp of the snf, NOT APPLICABLE, since 01/01/2011
• GILLIS, ERIC — managing control - governing body, NOT APPLICABLE, since 01/01/2011
• GILLIS, ERIC — operational/managerial control, NOT APPLICABLE, since 01/01/2011
• HUDMAN, EUGENE — managing control - governing body, NOT APPLICABLE, since 11/10/2021
• HUDMAN, EUGENE — operational/managerial control, NOT APPLICABLE, since 11/10/2021
• HUDMAN, EUGENE — adp of the snf, NOT APPLICABLE, since 11/10/2021
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• TAYLOR, STEPHEN — corporate officer, NOT APPLICABLE, since 07/01/2025
• CARETRUST GP LLC — adp of the snf, NOT APPLICABLE, since 01/01/2011
• CARETRUST REIT INC — adp of the snf, NOT APPLICABLE, since 01/01/2011
• CTR PARTNERSHIP LP — adp of the snf, NOT APPLICABLE, since 01/01/2011
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/01/2015
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 11/23/2010
• SOUTHERN OAKS HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 08/13/2025
• SOUTHERN OAKS HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• WISTERIA HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 01/01/2011