Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masonicare At Bishop Wicke Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities experienced progressive weight loss that culminated in a documented 22 lb. drop within about one month, along with frequent poor meal intake. Despite care plan directives and facility policy requiring monitoring of weights, re‑weighing for significant changes, and notification of the RD and physician, staff did not obtain a confirming re‑weight, did not investigate the cause of the loss, and did not notify the RD or physician. Nursing notes did not address the resident’s poor oral intake, and no nutritional interventions were initiated. A family member’s repeated concerns about weight loss and a request for dietary supplements were not acted upon, and the RD reported not being informed of any weight‑related concerns prior to the resident’s hospitalization, where severe malnutrition and significant weight loss were formally identified.
A resident with severe cognitive impairment and multiple chronic conditions experienced a progressive and then marked weight loss, along with poor meal intake, without timely notification of the physician, RD, or the resident’s representative. The care plan and facility policy required monitoring for significant weight changes, re-weighing to verify discrepancies, and notifying the RD, physician, and family when significant loss occurred. Despite documented weight decline and low or undocumented meal consumption, nursing notes did not identify a cause or show that appropriate notifications were made. A family member had voiced concerns about the resident’s weight and requested a dietary supplement, but the charge LPN reportedly indicated the weight was unchanged and no supplement was initiated, and the RD reported not being informed of the weight loss or concerns.
A resident with Alzheimer’s, Parkinson’s-related impaired mobility, TIA, and depression, who required assistance with ADLs and ambulation, experienced a fall while attempting to go to the bathroom and was found prone on the floor after hitting the head. Although a Post Fall assessment form was initiated and the provider ordered transfer to the ED, the clinical record did not show completion of the required Fall Risk assessment and Post Fall evaluation as outlined in facility policy. The ADON confirmed that each fall should trigger these assessments and that the assigned nurse is responsible for completing them, but this did not occur in this case.
Failure to provide a resident’s diet consistent with documented garlic allergy/intolerance. A resident with HTN, GERD, and gout had garlic listed in the chart and care plan, yet was served spaghetti and meatballs with garlic vegetables and later chicken noodle soup that also contained garlic. Dietary and nursing staff were unaware of the garlic restriction or failed to verify ingredients, and the physician later stated he was unaware garlic had been listed as an allergy.
Food items were found in the kitchen and storage areas without proper opened, expired, or used-by dating, including repackaged turnovers, thawed ground veal, expired seasoning, and other opened dry goods. During food service observation, multiple staff members placed on and removed gloves without washing or sanitizing their hands, despite the facility policy requiring proper hand hygiene before glove use and during food prep.
Failure to perform hand hygiene during wound care. A resident with severe cognitive impairment and a DTI on the left heel had wound care observed, and an LPN did not clean his hands before the procedure or when changing gloves. The LPN said he did not think of it and was unaware of the hand hygiene policy. The infection prevention nurse and DON stated hand hygiene should occur at the start and end of wound care and when gloves are changed, while the facility policy addressed hand sanitizer use after PPE removal and before and after resident care.
Failure to update the care plan after repeated falls: A resident with osteoarthritis, gout, and adjustment disorder had a BIMS score of 13 and was identified as a fall risk. After multiple unwitnessed falls, including one that resulted in a head injury and ER transfer, the care plan was not revised to add a new intervention, despite facility policy requiring care plan updates after a fall.
Incomplete Neurological Checks After Unwitnessed Falls: Two severely cognitively impaired residents had unwitnessed falls, including one with head hematoma and another with chest pain/contusion, yet required neuro checks were not fully completed on multiple occasions. The DON stated neuro checks should be completed for all cognitively impaired residents after unwitnessed falls and that the forms must be filled out completely, but staff did not complete all indicated assessments.
Failure to identify and address a resident’s decline in verbal communication after dental extractions. A resident with CVA-related deficits and moderate cognitive impairment had clear speech on the MDS, but later became completely edentulous and was observed with unintelligible speech. ST, nursing, rehab, and SW were unaware of or did not act on the change, and the care plan did not address the communication decline or use of AAC supports.
A resident with dementia, CHF, and a stage 3 pressure ulcer had an alternating pressure mattress ordered at 150 lbs. with shift checks, but repeated observations found it set at 200 lbs. An LPN acknowledged the setting was incorrect and had not been checked that shift, and the DON and ADON confirmed the mattress should have been set per the MD order.
Failure to Follow Transfer Plan and Update Fall Interventions: A resident with gait impairment and Parkinson’s disease was transferred to the toilet without following the care plan requiring 2-person assistance, and the resident reported feeling rushed during the transfer. Another resident with Alzheimer’s disease and high fall risk had repeated unwitnessed falls, but the RCP was not updated with new interventions after several events, and wheelchair equipment required by the RCP was not consistently in place.
Failure to replace a resident’s nebulizer mask and tubing per policy. A resident with COPD, HF, and anemia had nebulizer equipment dated weeks earlier and observed stored uncovered and exposed in the room. An LPN acknowledged the tubing should have been replaced weekly and that the equipment was not in a storage bag as required by policy.
Antibiotic stewardship documentation was deficient because the facility did not document a 48-to-72-hour antibiotic time-out review and did not ensure practitioners recorded the rationale for continuing antibiotics when McGeer’s criteria were not met. Staff reported there was no documented look-back process in the antibiotic use log, no consistent communication to providers about individual resident reviews, and no system to monitor practitioner documentation of continued antibiotic use.
Pneumococcal vaccination was not offered or documented for two residents. One resident had heart disease and HTN, intact cognition, and prior PCV13 history with CDC guidance indicating a later PCV20 or PCV21 dose was due, but the record lacked consent or evidence of follow-up vaccination. Another resident had HF, DM2, severe cognitive impairment, and total ADL dependence, but the chart lacked signed consent, nursing documentation, or vaccination history; an unsigned worksheet noted PCV23 was declined. An RN stated the facility should have offered the vaccines and could not locate consent or documentation for either resident.
A resident with Alzheimer's and mobility issues fell from bed and fractured their ankle due to improper positioning by a nursing assistant. The resident's care plan required maximum assistance for bed mobility, but the NA failed to reposition the resident's legs away from the bed's edge, leading to the fall. The resident sustained fractures and required hospital evaluation.
Failure to Identify and Address Significant Weight Loss and Malnutrition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutrition and timely identification and response to significant weight loss for one resident with vascular dementia, COPD, GERD, depression, and severe cognitive impairment. The resident’s care plan identified a self-care deficit and nutritional risk, with interventions including supervision during meals, monitoring for dysphagia, and reporting significant weight changes to the RD and physician. Physician orders specified a regular diet with regular texture and thin liquids. Facility policy required nurses to review all weights, obtain a re‑weight for discrepancies of plus or minus five pounds, and, if verified, notify the RD, physician, and family. From late May to early November, the resident’s weight gradually declined from 134 lbs. to 127.6 lbs., then a weight of 105.6 lbs. was documented on 12/3/25 by an LPN. Despite this apparent 22 lb. loss from the prior recorded weight, there was no documented re‑weight to confirm accuracy, no documented assessment of the cause, and no notification to the RD or physician. Food intake records from early November to early December showed that out of 84 meals, the resident consumed less than 50% or had no intake documented for 45% of meals, yet nursing notes during this period did not address poor oral intake, did not identify a cause for the weight loss, and did not document any nutritional interventions. Family concerns about the resident’s weight loss were also not acted upon. A family member reported raising concerns about weight loss with the day‑shift LPN in September and October and was told the weight was unchanged; the family member also requested a dietary supplement that was never started. The DON later stated that the charge nurse was responsible for checking weights, obtaining re‑weights for significant changes or when families voiced concerns, and notifying the RD and physician, and acknowledged that this did not occur. The RD reported not being informed of the significant weight loss or any concerns, and therefore did not have the opportunity to reassess or recommend interventions prior to the resident’s subsequent hospitalization, where severe malnutrition and a 28% one‑month weight loss were identified.
Failure to Notify Physician, RD, and Family of Significant Weight Loss and Decline in Nutritional Status
Penalty
Summary
The facility failed to ensure timely notification of the physician, RD, and resident representative when a resident experienced significant weight loss and a decline in nutritional status. The resident had vascular dementia with severe cognitive impairment, a history of falls, COPD, GERD, and depression, and required supervision with eating. The care plan directed staff to monitor for and report significant weight loss and to have the RD evaluate and make diet changes as needed. Weight records showed a gradual decline from 134 lbs. in late May to 127.6 lbs. in early November, followed by a documented weight of 105.6 lbs. in early December. Food intake logs from early November to early December showed that less than 50% of meals were consumed or not documented for 45% of meals. Nursing notes during this period did not identify a cause for the significant weight loss and did not document any notification to the RD or physician. The facility’s weight policy required nurses to review all weights, re-weigh residents when a discrepancy of plus or minus 5 lbs. was identified, and notify the RD, physician, and family if a gain or loss was verified. The resident’s family member reported concerns about weight loss to the charge LPN in September and October and requested a dietary supplement, but the LPN reportedly stated the weight was unchanged and no supplement was started. The DON stated that the charge nurse was responsible for checking weights, re-weighing residents when significant changes were noted or when family concerns were voiced, and notifying the RD and physician if significant weight loss was confirmed, and acknowledged that this process was not followed. The RD reported not being informed of the significant weight loss or any concerns about the resident’s weight and stated that, if informed, she would have requested a re-weight and reported to the physician for new interventions. Hospital records later documented a substantial weight loss, high nutritional risk, and severe malnutrition, but there was no evidence in the facility’s documentation that the significant weight loss identified on the facility’s weight log had been verified, investigated, or communicated to the physician, RD, or the resident’s representative as required by the facility’s policy and the resident’s care plan.
Failure to Complete Required Post-Fall Evaluation and Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-fall evaluations and assessments in accordance with its own policies after a resident fall. A resident admitted in December 2025 with Alzheimer’s disease, transient ischemic attack, depression, and impaired physical mobility related to Parkinson’s disease had been care planned as being at risk for falls and required assistance with personal hygiene, toileting, bathing, and transfers/ambulation with a walker. The admission MDS documented moderate cognitive impairment and a need for substantial assistance with activities of daily living and mobility. On 12/26/25 at 7:03 AM, the resident was found on the floor in a prone position between the bed and closet after attempting to go to the bathroom and hitting his/her head. The provider was notified and ordered transfer to the emergency department. Although a Post Fall assessment was completed for this fall event, the clinical record showed that the required Fall Risk assessment and Post Fall evaluation were not completed. In an interview, the ADON stated that each fall incident should be followed by a Fall Risk assessment and Post Fall evaluation, and that it was the responsibility of the assigned nurse to complete these documents. Facility policies directed that a fall risk evaluation be performed on admission, with change of condition, annually, quarterly, or as needed, and that all residents be assessed for potential/actual injury after a fall, but these requirements were not fully carried out for this resident’s fall.
Failure to Provide Diet Consistent With Documented Garlic Allergy/Intolerance
Penalty
Summary
The facility failed to provide the correct diet for a resident with documented food allergies and dietary preferences. The resident had diagnoses including hypertension, GERD, and gout, and the clinical record showed a physician order identifying an allergy to garlic. The resident care plan also identified a nutritional problem related in part to a food allergy to garlic and directed the facility to provide the ordered diet and evaluate dietary changes as needed. Dietary assessments and a multidisciplinary care conference note continued to document garlic as an allergy. The resident told surveyors that the facility continued to serve food with garlic despite the request to avoid it, and stated that garlic caused stomachache and gastrointestinal issues. During observation, the resident’s lunch tray contained spaghetti and meatballs with squash. The Director of Dietary Services stated she was aware of allergies to melon, shellfish, and bananas, but did not identify garlic as a documented allergy. She also confirmed that both the spaghetti and meatballs and the garlic vegetables contained garlic as an ingredient, and that the resident had been served spaghetti and meatballs with a double portion of garlic vegetables. Additional interviews showed breakdowns in communication and food preparation. A dietary aide stated she was responsible for entering food allergies into the kitchen census and believed the garlic allergy was missing because of a cloud syncing problem. The DON stated nursing had been notified after the resident was served food containing the documented allergy. The resident later received chicken noodle soup, and the ADNS stated she delivered it without checking whether it contained garlic. A kitchen staff member stated the soup stock base did not list garlic, but garlic had been added during cooking. A subsequent resident nutrition interview identified garlic as a food intolerance, with gas as the symptom, while the physician later stated he was unaware garlic had been listed as an allergy and removed it from the allergy list.
Food Storage Dating and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure open food items were dated with opened, expired, and used-by dates in accordance with professional standards during a kitchen tour and interview with the Food Service Director. In freezer #2, surveyors found a previously opened and repackaged bag of raspberry turnovers with a handwritten best used by date of 6/7/25 and a previously opened and repackaged bag of apple turnovers with a handwritten best used by date of 7/11/25. In the refrigerator, a thawed package of ground veal had a handwritten thaw date of 9/2/25 and a handwritten note to use it by 9/4/25. Under the prep counter, surveyors also observed an unopened expired 16 oz chili powder container with a manufacturer best buy date of 2/6/25, an opened 16 oz container of basil leaves opened on 7/10/25 with no expiration date, an opened 16 oz container of cocoa powder with no open date and an expiration date of 8/29/25, an opened 16 oz container of granulated garlic without an opening date and a manufacturer expiration date of March 2029, an opened 16 oz container of granulated onion without an opened date but with a handwritten received date of 7/30/25, an opened 16 oz container of Italian seasoning dated to be opened on 6/5/25 without an expiration date or used-by date, and a partially used 50 lb bag of red velvet cake mix with a handwritten opened date of January 2025 and a best used by date of March 2025. The facility also failed to ensure staff performed hand hygiene before placing gloves on during food preparation and food service. During food service observation with the Food Service Director present, five staff members were observed placing and removing gloves without sanitizing or washing their hands. One staff member failed to sanitize or wash hands three times, another failed twice, and three dietary aides each failed to wash or sanitize twice. The facility policy reviewed by surveyors stated that hand contact with food shall be restricted and proper hand hygiene shall be used, with plastic/vinyl, non-latex gloves used when contacting and preparing food.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene during wound care for a resident with peripheral vascular disease, dementia, and traumatic brain injury. The resident’s admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and dependence for personal hygiene, rolling, and chair/bed-to-chair transfers. The resident also had an unstageable pressure ulcer identified as a deep tissue injury on the left inner heel, and the care plan directed treatment of the wound, Enhanced Barrier Precautions, and use of facility policies and protocols for skin breakdown prevention and treatment. A nursing note documented a new facility-acquired pressure ulcer on the left heel measuring 5.3 cm by 5.5 cm with no depth and a base described as deep red, maroon, or purple. During observation of wound care, an LPN did not perform hand hygiene before wound care and did not perform hand hygiene when changing gloves during the procedure. The LPN stated he did not think of it and said he had not received training on and was unaware of the facility’s hand hygiene policy. The infection prevention nurse and DON stated that hand hygiene should be performed when entering or leaving a resident room, before applying gloves, after glove removal, and at the beginning and end of wound care and when changing gloves. The facility’s hand hygiene policy stated that hands should be washed with alcohol-based hand sanitizer after removing PPE and before and after giving care to each resident, but it did not identify that alcohol-based hand sanitizer should be used before donning PPE.
Failure to Update Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise Resident #93’s Resident Care Plan after a fall that resulted in hospitalization. Resident #93 had diagnoses including osteoarthritis, gout, and adjustment disorder, and the admission MDS showed a BIMS score of 13 with partial/moderate assistance needed for lower body dressing and transfers. The resident’s care plan identified a fall risk related to weakness and included interventions such as anticipating needs, appropriate footwear, maintaining a safe environment, keeping the call light and personal items in reach, and keeping the bed in low position. The physician orders for the relevant period did not include fall prevention measures. The resident experienced multiple unwitnessed falls, including falls on 8/30/25 and 9/1/25, after which new interventions were added to the care plan. On 9/4/25, the resident had another unwitnessed fall and was found on the bathroom floor after hitting his/her head, which resulted in transfer to the Emergency Room. Review of the Resident Care Plan failed to show that it had been revised to include a new intervention after this fall. The RN Supervisor stated that the facility policy directed the supervisor to initiate a new intervention after a resident fell, and the DON stated nursing staff were to update the care plan with a new intervention following a fall, but no new intervention was placed on the resident’s care plan after the fall that led to hospitalization.
Incomplete Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure neurological assessments were completed after unwitnessed falls for 2 of 2 residents reviewed for skin issues. Resident #49 had diagnoses including Alzheimer's disease, hypertension, and anxiety, was severely cognitively impaired, used a wheelchair, and required extensive assistance with mobility and transfers. After an unwitnessed fall in the resident's room, neurological checks were initiated per protocol, but the Head Injury Flow Sheet showed that 3 of 20 required neurological checks were not completed. A second unwitnessed fall occurred later, with the resident found lying on the floor on the left side in a fetal position, complaining of pain to the left hip and the back of the head where a large hematoma was noted; again, 3 of 20 required neurological checks were not completed. Resident #109 had diagnoses including hypertension, overactive bladder, and unspecified falls, and had severe cognitive impairment with dependence for transfers and toileting. After an unwitnessed fall while attempting to ambulate to the bathroom, the resident complained of mild to moderate chest pain that worsened with palpation and deep breaths, and the physician documented a contusion to the right front wall of the thorax. The neurological flow sheet for this event showed that 2 of 20 required neurological checks were not completed. A later unwitnessed fall occurred when the resident attempted to get out of bed unattended to use the bathroom and slipped onto the floor without injury. For that later fall, the resident's care plan was not updated with a new intervention, and the neurological flow sheet showed that 7 of 20 required neurological checks were not completed. The Director of Nursing Services stated that neurological checks should be completed for all residents who sustained an unwitnessed fall and hit their head, and for cognitively impaired residents who had an unwitnessed fall, and that the form must be filled out completely for all indicated times. The DNS also stated that charge nurses and nursing supervisors were responsible for ensuring the neurological assessments were thoroughly completed, but could not explain why staff were not completing them.
Failure to Identify and Address Decline in Resident Communication
Penalty
Summary
The facility failed to identify and respond to a change in a resident’s verbal communication ability after multiple dental extractions left the resident completely edentulous. The resident had diagnoses including cerebral infarction, acquired deformity of head, left-sided hemiplegia, and adjustment disorder with depressed mood. The annual MDS showed the resident had moderate cognitive impairment, clear speech with distinct intelligible words, and required assistance with some ADLs. The resident care plan addressed oral/dental issues and possible chewing or swallowing problems, but it did not address any change in communication ability. After a hospitalization for aspiration pneumonia, speech therapy saw the resident for dysphagia management and documented intact motor speech skills, but did not evaluate speech or communication. Dental notes later documented multiple surgical extractions, with the resident becoming completely edentulous after the last extraction. The annual LTC evaluation failed to identify any change in the resident’s ability to communicate verbally, despite the change in dental status and the later observed unintelligible speech. During observation, the resident had unintelligible, unclear speech when answering questions requiring more than yes/no responses, and no AAC devices were present or being used. Family reported the resident had previously spoken in complete sentences and that speech changed after tooth extractions; they also reported asking staff for help with communication during care plan meetings without receiving assistance. Staff interviews showed nursing, rehab, social work, and speech therapy were unaware of or did not act on the communication change, and the facility’s communications policy addressed admission assessment but did not identify reassessment after admission for changes in speech or edentulous status.
Incorrect Alternating Pressure Mattress Setting
Penalty
Summary
The facility failed to set an alternating pressure mattress at the physician-ordered setting for a resident with Alzheimer’s disease, vascular dementia, and systolic congestive heart failure who was dependent on staff for toileting hygiene, bed mobility, and transfers. The quarterly MDS identified the resident had a stage 3 pressure ulcer that was not present on admission and that a pressure-reducing device was in use. The care plan identified a coccyx pressure ulcer related to immobility and bowel/bladder incontinence, and the Braden Scale identified the resident as high risk for pressure ulcer development. A physician’s order directed the alternating pressure mattress to be set at 150 lbs. and checked every shift, but observations on multiple occasions showed the mattress set at 200 lbs. When the LPN was interviewed, the resident was observed sleeping in bed with the mattress still set at 200 lbs., and the LPN stated the setting was incorrect and that she had not checked it that shift. The LPN then changed the setting to 150 lbs. The DON and ADON stated the mattress should have been set according to the physician’s order, and the facility policy directed pressure-relieving mattresses to be set per the physician order.
Failure to Follow Transfer Plan and Update Fall Interventions
Penalty
Summary
The facility failed to transfer a resident according to the plan of care, resulting in a fall. Resident #16 had diagnoses including pain in the left hip, abnormalities of gait and mobility, Parkinson’s disease, psychotic disturbance, and anxiety. The quarterly MDS identified that the resident had a BIMS score of 14, indicating no cognitive impairment, and required a wheelchair or walker for mobility with partial/moderate assistance for bed mobility, toileting, and bathing transfers. The resident’s undated NA Resident Care Card directed that the resident required the assistance of 2 with ambulation and transfers. A Facility Reported Incident form stated that Resident #16 reported being pushed down by an NA during transfer to the toilet. In the investigation, the resident stated that he or she did not believe the NA was intentionally trying to hurt him or her, but felt rushed. The NA stated that during the transfer the resident’s feet became twisted and were close to the bar next to the toilet, and that the NA used the resident’s brief to guide the resident onto the toilet. The NA stated the resident used the restroom and offered no complaints, and also stated that the resident was not observed hitting the bar during the transfer. For Resident #49, the facility failed to implement new RCP interventions following repeated falls and failed to use wheelchair equipment according to the RCP. Resident #49 had diagnoses including Alzheimer’s disease, hypertension, and anxiety, and was identified as a high fall risk. The quarterly MDS showed severely impaired cognition, dependence for transfers, and dependence or substantial assistance for mobility. The RCP identified fall-risk interventions including keeping the call light in reach, prompt response, the falling star program, Dycem above and below the wheelchair cushion, PT evaluation and treatment as needed, and review of past falls to determine root causes and alter or remove causes if possible. The resident had multiple unwitnessed falls in the room, including being found on the floor behind the door, on the floor beside the bed, and on the knees facing the bed with the wheelchair behind the resident and the wheels unlocked. After several of these falls, the clinical record documented that all RCP interventions were reviewed and appropriate, and no new intervention was implemented. A later post-fall note identified the resident lying on the floor next to the bed and stated that potential alternative measures included UTI protocol and placement of anti-rollback devices on the wheelchair. During observation, the resident was seen in a wheelchair without an anti-rollback device attached, and the wheelchair was later found in another resident’s room. The DON stated that when a resident fell repeatedly during the same type of activity, a new intervention should be added or the current intervention changed, and that fall assessments should have been completed after each fall.
Failure to Replace Nebulizer Equipment per Policy
Penalty
Summary
The facility failed to change Resident #68’s nebulizer mask and tubing according to facility policy. Resident #68 had diagnoses including anemia, heart failure, and chronic obstructive pulmonary disease. The quarterly MDS identified intact cognition with a BIMS score of 13 and need for substantial to maximal assistance with upper and lower body dressing and transfers, and partial to moderate assistance with bed mobility. A physician’s order dated 8/25/25 directed Ipratropium-Albuterol inhalation solution to be used with the resident’s nebulizer as needed every 6 hours for shortness of breath while awake. Observations showed the resident’s nebulizer tubing was dated 7/18/25 and was stored uncovered and exposed to the environment on 9/10/25, 9/12/25, and 9/15/25. Review of the MAR showed the resident last received a nebulizer treatment on 9/13/25 at 6:03 AM. During interview and observation on 9/15/25, an LPN identified the nebulizer mask and tubing were still dated 7/18/25 and stored on the arm of the recliner. The LPN stated the policy required nebulizer masks and tubing to be replaced every Wednesday on the 11:00 PM to 7:00 AM shift and acknowledged responsibility for not replacing the equipment and not ensuring a storage bag was present.
Antibiotic Stewardship Documentation Deficiencies
Penalty
Summary
The facility failed to document a 48-to-72-hour review of antibiotic use and failed to ensure practitioners documented the rationale for continuing antibiotics when McGeer’s criteria were not met. During review of the infection control program, the Infection Control Nurse, RN #1, and the ADNS identified that the facility used McGeer’s criteria as a guide to determine whether antibiotic use was appropriate for a suspected or diagnosed infection, but the practice did not include documentation of that review. A review of the resident antibiotic use log did not identify any area to document a 48-to-72-hour look back or any documentation that such a review had occurred to determine whether the antibiotic remained necessary. RN #1 stated that she did not conduct the 48-to-72-hour time out for resident antibiotic use and was unable to explain why the review was not completed per facility policy. The facility also did not have a system to ensure practitioners documented the rationale for continued antibiotic use when the antibiotic was contraindicated or when use was based on practitioner judgment. RN #1 could not explain how this expectation was communicated to practitioners or how compliance was monitored. An APRN stated that the facility had never communicated an individual resident review of antibiotic use or a formal process since she started in March 2025, and the Medical Director stated that he did not always document the rationale for continuing antibiotic use, although he acknowledged that if this was the policy and recommended practice for antibiotic stewardship, the facility should be following it.
Pneumococcal Vaccination Not Offered or Documented
Penalty
Summary
The facility failed to ensure the pneumococcal vaccine was offered for 2 of 5 sampled residents, Resident #86 and Resident #88. Resident #86 was admitted in January 2020 and had diagnoses of heart disease and hypertension. The quarterly MDS assessment identified intact cognition with a BIMS score of 15 and moderate assistance needed with ADLs. The care plan dated 9/12/25 did not address vaccination status. The clinical record showed Resident #86 received PCV13 in July 2021, and CDC guidance indicated a dose of PCV20 or PCV21 was due one year later. However, the record did not identify consent to offer additional vaccinations or documentation that any further pneumococcal vaccination had been administered. Resident #88 was admitted in March 2024 and had diagnoses of heart failure and type 2 diabetes. The quarterly MDS assessment identified extreme cognitive impairment with a BIMS score of 4 and total dependence for ADLs. The care plan dated 9/5/25 did not address vaccination status. The clinical record did not contain a signed consent or nursing documentation of pneumococcal vaccination status, and there was no information showing a pneumococcal vaccination history. An unsigned, undated vaccination worksheet indicated PCV23 had been declined, and the form stated educational and consent forms should be given to residents and/or resident representatives whether they chose vaccination or wished to consult later with their attending physician. RN #1 stated the facility should have offered vaccinations to both residents and could not find consent forms or documentation for either resident.
Resident Falls from Bed Due to Improper Positioning
Penalty
Summary
The facility failed to ensure proper positioning of a resident prior to providing care, resulting in a fall from bed and a fractured ankle. The resident, who had Alzheimer's disease, osteoarthritis, and mobility abnormalities, required maximum staff assistance for bed mobility. The care plan indicated that one staff member should assist with bed mobility. However, during an incident, a nursing assistant (NA) asked the resident to turn onto their side for care, but the resident rolled out of bed before the NA could intervene, leading to the fall. The incident report and interviews revealed that the resident's legs were positioned too close to the edge of the bed before being turned, which contributed to the fall. The NA acknowledged that they should have repositioned the resident's legs to the center of the bed or closer to their position to prevent the fall. The resident sustained oblique transverse fractures of the distal tibial and fibular metaphyses, confirmed by an x-ray, and was diagnosed with a left ankle fracture. The resident was transferred to the hospital for evaluation and returned with specific care instructions for the injury.
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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.
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Nursing homes near Shelton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardner Heights Health Care Center, Inc | 0.3 mi | ★★★★★ | 5 | 0 |
| Hewitt Health & Rehabilitation Center, Inc | 2.1 mi | ★★★★★ | 2 | 0 |
| Lord Chamberlain Nursing & Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Lord Chamberlain Manor Nursing & Rehabilitation Ce | 2.4 mi | ★★★★★ | 5 | 1 |
| Apple Rehab Shelton Lakes | 2.4 mi | ★★★★★ | 4 | 0 |
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