Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Center during CMS and state inspections, most recent first.
The facility failed to ensure proper food safety and hygiene practices in the kitchen. Staff with facial hair, including the Executive Chef, were not wearing beard guards while preparing food, as the facility had not provided them. Additionally, several food items in the kitchen were improperly stored, not dated, or exceeded their storage life, contrary to the facility's policy.
The facility failed to document and obtain consent for advance directives for three residents. One resident had conflicting code status documentation, another lacked a signed Advance Directives Summary form despite a CPR order, and a third resident with a terminal prognosis had no documented advance directive form. Staff acknowledged the absence of necessary documentation and consent, which should have been completed during the admission process.
The facility failed to maintain a safe and clean environment, as evidenced by drywall residue left in hallways and deficiencies in a resident's room, including a partially attached window curtain, a soiled privacy curtain, and an exposed cable wire. Despite acknowledgment of these issues, they remained unaddressed, compromising the resident's environment.
Three residents with dementia were placed in a secured unit without proper documentation of clinical criteria or evidence that it was the least restrictive setting. The facility failed to document the involvement of responsible parties or the interdisciplinary team's assessment of the impact of the placement. Observations showed residents were calm and cooperative, yet their care plans did not reflect the necessity of the secured unit.
The facility failed to follow its Water Management Plan by not conducting monthly Legionella testing and not reporting positive results to the State Agency. Missing testing results for 2022, 2023, and 2024 were identified, and multiple positive Legionella samples were not reported. The Director of Maintenance and Administrator were unaware of all positive results, despite the facility's policy to report them.
A resident with dementia and mobility issues sustained a skin tear during a transfer, but the facility failed to update the care plan to include accident prevention measures. The ADNS admitted the care plan should have included re-education for the nursing assistant involved, but this did not occur.
The facility did not complete an annual performance evaluation for a nurse aide hired in 2010, with missing evaluations for 2022, 2023, and 2024. The administrator confirmed that annual reviews should occur on the hire date anniversary, but no documentation was found. The unit manager was responsible for these evaluations, and the facility lacked a policy for performance evaluations.
The facility failed to document and act on pharmacy consultant recommendations for two residents. One resident was prescribed Seroquel without a clear diagnosis, and the recommendation to review this was not addressed. Another resident had a delayed TSH level check recommendation following a Levothyroxine dosage change. Delays in forwarding recommendations to APRNs led to untimely reviews, contrary to the facility's policy requiring action within 30 days.
The facility was found to have a medication error rate of 12%, exceeding the acceptable threshold of 5%. This was determined through a review of clinical records and facility policies, highlighting a significant issue in medication administration practices.
In a dementia unit, an LPN left a medication cart unsecured while attending to a resident, leaving it unattended and out of sight. Interviews confirmed that the cart should have been secured, as per facility policy, especially given the cognitive deficits of the residents on the floor.
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. One resident, who was cognitively intact, did not receive the vaccine despite giving consent. Another resident, with severely impaired cognition, was not offered the PCV20 vaccine upon admission, despite being eligible. The facility's policy required offering pneumococcal immunizations as recommended by the CDC, but this was not followed, and necessary documentation was not completed.
A resident with multiple medical conditions did not have Social Security funds deposited into their personal fund account in a timely manner. The Business Manager, responsible for transferring funds from the trust account, failed to do so due to confusion over a check, despite being aware of the expected payment. This resulted in the resident not having timely access to their funds as required by facility policy.
A resident with cognitive impairment and mobility deficits, requiring a two-person assist for transfers, sustained a skin tear to the lower leg during a transfer to bed. Facility records and staff interviews indicated uncertainty about whether wheelchair leg rests were removed prior to the transfer, and the facility could not provide an accident prevention policy when requested.
A resident dependent on staff for transfers and at high risk for falls was improperly transferred using a mechanical lift when a nurse aide inadvertently pressed the remote, causing the sling to recline and a strap to disconnect. The resident fell, sustaining a head laceration and subdural hematoma, due to failure to follow proper two-person transfer technique.
A resident with dementia and anxiety was administered Trazodone for agitation, which proved ineffective. The LPN did not notify the physician or supervisor about the ineffectiveness, leading to the resident falling and sustaining a head injury. The facility's policy required notifying the physician of a change in condition, which was not followed.
A facility failed to create a comprehensive care plan for a resident with urinary incontinence. The resident, diagnosed with urinary retention and benign prostatic hyperplasia, was frequently incontinent after the removal of an indwelling urinary catheter. Despite this, no care plan was developed to address the incontinence, as confirmed by the DON. The facility's policy requires a patient-specific care plan, which was not followed.
A facility failed to conduct a continence assessment for a resident after removing an indwelling urinary catheter. The resident, with severe cognitive impairment and a history of urine retention, was frequently incontinent post-catheter removal. The facility's policy required a bowel and bladder assessment, which was not completed, as confirmed by the DON.
A resident with dementia and anxiety experienced increased agitation and restlessness, which were not effectively managed by the facility. Despite being administered Trazodone, the medication was ineffective, and staff failed to notify the physician or take further action. The resident fell from a wheelchair, sustaining a head injury. Additionally, the facility did not consistently document the resident's behaviors, contributing to inadequate management.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a survey. Several staff members, including the Executive Chef and other kitchen staff with facial hair, were found not wearing beard guards while preparing food. The Executive Chef acknowledged that the facility did not have beard guards available, although they were ordered but not yet received. Interviews with staff revealed that the facility had not offered beard guards, and some staff believed that keeping their beards short negated the need for a guard. The facility's policy required all facial hair to be restrained with a beard net or restraint. Additionally, the facility failed to adhere to its food storage policy. Observations in the kitchen identified several food items that were either not dated, improperly covered, or had exceeded their storage life. Prepared foods such as cheese blitzes, stuffed peppers, meatballs, and ground meat were found in the walk-in refrigerator beyond the three-day limit for use. The Executive Chef confirmed that these items should have been discarded and acknowledged that the weekend staff should have removed the out-of-date food. The facility's policy required refrigerated foods to be discarded after three days from being opened or prepared.
Failure to Document and Obtain Consent for Advance Directives
Penalty
Summary
The facility failed to ensure proper documentation and consent for advance directives and code status for three residents. Resident #18 was admitted with severe cognitive impairment and had conflicting documentation regarding their code status. The electronic record indicated a DNR status, while the physical record had an incomplete DNR form. The responsible party initially wished for a DNR status but later confirmed a full code status after the facility sought clarification. Resident #22, who was cognitively intact, did not have a signed Advance Directives Summary form in either the physical or electronic records, despite a physician's order indicating a CPR code status. The resident did not recall any discussion about advance directives or code status upon admission. The facility's staff acknowledged the absence of the necessary documentation and consent, which should have been completed during the admission process. Resident #128, with severe cognitive impairment and a terminal prognosis, also lacked a documented advance directive form in both the electronic and physical records. The physician's orders indicated a DNR status, but there was no written consent from the responsible party. The facility's staff confirmed the absence of the required documentation and noted that the advance directive should have been verified and documented within the first three days of admission.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations and interviews conducted during the survey. On the 3 Ramage unit, a hole in the wall was noted due to a water leak, and maintenance staff were present but not actively working on repairs. The base molding was missing throughout the unit. Additionally, drywall residue from preparation for painting was found clumped on the floors, spread across hallways, and tracked by residents, indicating inadequate cleanup by the work crew. The facility manager acknowledged that the staff should have cleaned up the mess at the end of the day. Resident #80's room was observed to have several deficiencies, including a window curtain that was only partially attached, exposing metal hooks, a soiled bedside privacy curtain with brownish, reddish splatters, and a cable wire protruding from the wall without a cover. Despite the LPN's acknowledgment of the issues and the intention to address them, subsequent observations showed that the deficiencies remained unaddressed, indicating a lack of timely action to ensure a safe and homelike environment for the resident.
Lack of Documentation for Secured Unit Placement
Penalty
Summary
The facility failed to ensure proper documentation and criteria for placing residents in a secured unit, affecting three residents with dementia. Resident #13, diagnosed with dementia, bipolar disorder, and liver cancer, was placed in a secured unit without documented clinical criteria or evidence that it was the least restrictive setting. Despite being pleasant and without unwanted behaviors, the resident's care plan included a wander guard, and there was no documentation of the resident's or responsible party's involvement in the decision. Resident #38, with dementia and a history of combative behaviors, was also placed in the secured unit without proper documentation. The resident's clinical record lacked evidence of the interdisciplinary team's assessment of the impact of the placement or the involvement of the responsible party. Observations showed the resident was calm and cooperative, yet the facility did not document the necessity of the secured unit as the least restrictive environment. Similarly, Resident #82, with dementia and heart failure, was placed in the secured unit without documented clinical criteria or evidence of the least restrictive setting. The resident's care plan did not reflect the secured unit placement, and there was no documentation of the responsible party's involvement. The facility's assessment failed to identify criteria for placement in secured units, and the interdisciplinary team's discussions were not adequately documented in the residents' clinical records.
Failure to Report Positive Legionella Results
Penalty
Summary
The facility failed to adhere to its Water Management Plan, which required monthly Legionella testing, and did not report positive Legionella water sampling results to the State Agency. The facility's documentation review revealed missing Legionella testing results for several months in 2022, 2023, and 2024. Interviews with the Director of Maintenance and the Administrator confirmed that they were unable to provide the missing testing results and the water management plan binder. The Director of Maintenance was responsible for obtaining and maintaining copies of the Legionella water sampling results, but failed to do so. The facility's Water Management Plan identified multiple instances of positive Legionella water sampling results that were not reported to the State Agency. These results included several months in 2023 and 2024 where testing locations showed Legionella pneumophila and other species above the threshold of 10 colony-forming units per milliliter or swab. Despite the facility's policy to report positive results to the State Agency, the Administrator was not aware of all positive results, and the Director of Maintenance failed to communicate these results to the Administrator. The Water Management Contractor, who conducted the monthly testing, confirmed that the facility was responsible for reporting positive results to the State Agency. The contractor provided recommendations for addressing positive results, which were followed by the facility. However, the facility did not maintain a complete record of testing results and failed to report positive findings as required. The Administrator and Director of Maintenance acknowledged the facility's practice of reporting positive results but did not provide a policy or plan related to the water management plan and reporting requirements.
Failure to Revise Care Plan After Resident Injury
Penalty
Summary
The facility failed to review and revise the care plan for a resident following an incident where the resident sustained a skin tear during a transfer. The resident, who had diagnoses including dementia and muscle wasting, was dependent on staff for transfers and used a wheelchair for mobility. On a specific date, a nurse noted an open area on the resident's lower right leg after a transfer, which was later identified as a skin tear. The facility's investigation determined that the injury occurred during the transfer to bed, but the care plan was not updated to include interventions for accident prevention, such as re-educating the nursing assistant involved in the transfer. The Assistant Director of Nursing Services (ADNS) acknowledged that the care plan should have been updated to include education for the nursing assistant on safe transfer techniques. However, this re-education did not occur. Additionally, a registered nurse could not recall specific details about the incident, and attempts to interview the nursing assistant involved were unsuccessful. The facility's policy requires that care plans be developed and revised as appropriate, but this was not adhered to in this case, leading to the deficiency.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of its nurse aides, identified as NA #4. NA #4 was hired on January 18, 2010, and there was no documentation of a performance evaluation for the years 2022, 2023, or 2024 in their personnel file. During an interview on December 3, 2024, the administrator confirmed that each employee should receive a performance review annually on their hire date anniversary. The unit manager was responsible for ensuring these evaluations were completed, but no documentation was found for NA #4's evaluations. Additionally, the facility could not provide a policy for performance evaluations when requested.
Failure to Document and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure proper documentation and timely action on pharmacy consultant recommendations for two residents. Resident #120, diagnosed with unspecified dementia, anxiety disorder, and heart failure, was prescribed Seroquel for agitation without a clear supporting diagnosis. A pharmacy consultant recommended a review of this medication, but the recommendation was not addressed by the APRN/Physician and was not included in the resident's clinical record. The APRN for Resident #120's unit indicated that she only reviews paperwork provided to her and does not receive pharmacy recommendations directly, leading to delays in addressing these recommendations. Similarly, for Resident #135, who had diagnoses including unspecified dementia with agitation and psychotic disorder, a pharmacy consultant recommended a TSH level check following a Levothyroxine dosage change. This recommendation was not documented in the clinical record until requested by a surveyor. The ADNS and unit managers receive pharmacy recommendations via email, but there are delays in forwarding these to the APRNs, resulting in untimely reviews. The facility's policy requires prescribers to act on recommendations within 30 days, but this was not adhered to, as evidenced by the delayed actions and incomplete documentation in the clinical records.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the required threshold of 5%. Upon review of clinical records and facility policies, it was found that the observed medication administration had a calculated error rate of 12%. This indicates a significant deviation from the acceptable standards for medication administration within the facility.
Medication Cart Security Lapse in Dementia Unit
Penalty
Summary
The facility failed to ensure the security of the medication administration cart in the locked down dementia unit. During an observation, an LPN was seen preparing medication and then leaving the cart unsecured as he walked into the dining room to administer medication to a resident. The cart was positioned near the entrance to the dining room, and all drawers were accessible. The LPN then left the cart unattended and out of his line of sight as he escorted a confused resident down the hallway to their room, approximately 50 feet away. Interviews with the LPN and the Assistant Director of Nursing Services (ADNS) confirmed that the medication cart should have been secured whenever the nurse was not in attendance. The facility's policy on Medication Ordering, Scheduling, and Administration also stipulated that medication carts must be maintained securely on the nursing unit, with main locks engaged when unattended. The ADNS acknowledged that the residents on this floor had cognitive deficits, emphasizing the importance of securing the cart even if it was within the nurse's view.
Failure to Administer Pneumococcal Vaccines as Requested
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. Resident #25, who was admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy, was cognitively intact and had given consent for the pneumococcal vaccine. However, the vaccine was not administered, and the Infection Preventionist nurse could not provide a reason for this oversight. The Director of Quality confirmed that it was the Infection Preventionist nurse's responsibility to track the resident's vaccine status. Resident #144, admitted with Alzheimer's disease, dementia, and depression, had severely impaired cognition. The legal representative of Resident #144 was provided with an incorrect consent form, and the resident was not offered the PCV20 vaccine upon admission, despite being eligible based on prior vaccination history. The facility's policy required offering pneumococcal immunizations as recommended by the CDC, provided there were no medical contraindications and consent was obtained. However, the policy was not followed, and the necessary documentation was not completed in the resident's medical record.
Failure to Timely Deposit Resident Personal Funds
Penalty
Summary
A deficiency occurred when the facility failed to deposit a resident's Social Security funds into the resident's personal fund account in a timely manner. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy, was identified as cognitively intact but dependent on staff for several activities of daily living and used a wheelchair for mobility. The responsible party for the resident reported that the resident was owed money from Social Security, and the Business Manager initially stated that the delay was due to the Social Security office. However, a review of the resident's accounts revealed that a deposit from the US Treasury had been received by the facility but was not transferred to the resident's fund account as required. Interviews with the Business Manager and the corporate Cash Specialist clarified that the Business Manager was responsible for transferring funds from the facility's trust account to individual resident accounts. The Business Manager admitted confusion regarding the check, despite being aware of the expected amount for the resident. The facility's policy required individual accounts for each resident with monthly reconciliation, but this process was not followed, resulting in the resident not having timely access to their funds.
Failure to Ensure Safe Transfer Results in Resident Skin Tear
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle wasting, atrophy, atrial fibrillation, and anxiety, who was dependent on staff for transfers and used a wheelchair for mobility, sustained a skin tear during a transfer to bed. The resident's care plan required a two-person assist for transfers, and the incident happened while a nursing assistant was assisting the resident back to bed. The skin tear was discovered on the resident's lower right leg, and the cause was determined to be related to the transfer process. Facility documentation and interviews revealed uncertainty about whether the wheelchair leg rests were removed prior to the transfer, which may have contributed to the injury. The facility was unable to provide a policy for accident prevention when requested. Staff interviews could not confirm the exact circumstances of the injury, and the nursing assistant involved was unavailable for interview. The incident was documented in the resident's clinical record and facility reports, and the wound was subsequently treated according to physician orders.
Improper Mechanical Lift Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, impaired mobility, and a high risk for falls was improperly transferred from bed to wheelchair using a mechanical lift. The resident was dependent on staff for all transfers and required two-person assistance with a Hoyer lift, as documented in the care plan. During the transfer, the nurse aide operating the lift held the remote in her hand while maneuvering the device, inadvertently pressing a button that caused the sling to recline. This action led to a strap disconnecting from the lift, resulting in the resident falling and striking their head on the lift. Clinical records and staff interviews confirmed that the transfer was not performed according to proper technique, as the second staff member was not in position to guide or support the resident during the maneuver. The resident sustained a scalp laceration, a bump on the head, and was diagnosed at the hospital with a subdural hematoma and bifrontal petechial hemorrhages, requiring admission for treatment and monitoring. The incident was attributed to improper handling of the lift controls and failure to follow established transfer protocols.
Failure to Notify Physician of Ineffective Medication
Penalty
Summary
The facility failed to notify a physician when a resident exhibiting behaviors was administered an as-needed medication that was ineffective. The resident, diagnosed with dementia and anxiety, was severely cognitively impaired and required extensive assistance. The care plan included administering medications as ordered and reporting restlessness and agitation. A physician's order directed the administration of Trazodone for anxiety, restlessness, or agitation. However, on a specific date, the medication was ineffective, and the staff did not notify the physician or take further action. On the day of the incident, the resident was agitated, self-propelling in a wheelchair, and calling out loudly. Despite attempts to calm the resident with food and redirection, the agitation persisted. An LPN administered Trazodone, which was ineffective, but did not notify the supervisor or physician about the ineffectiveness. Later, the resident fell from the wheelchair, sustaining a head injury, and was transferred to the hospital. The nursing staff had not communicated the ineffectiveness of the medication to the physician, missing an opportunity for further intervention. Interviews with staff and the psychiatric provider revealed that the facility had been managing the resident's behaviors with medication adjustments. The psychiatric provider indicated that if notified of the continued agitation, he could have adjusted the medication dosage. The facility's policy required notifying the physician of a change in condition, which was not followed in this case. The DNS and Administrator acknowledged that the nurse should have reported the medication's ineffectiveness to the supervisor, who could have contacted the physician for further direction.
Failure to Develop Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with urinary incontinence. The resident, who had a diagnosis of urinary retention and benign prostatic hyperplasia, was identified as having severe cognitive impairment and required extensive assistance with Activities of Daily Living (ADLs). An admission Minimum Data Set (MDS) assessment noted the presence of an indwelling urinary catheter, which was later discontinued per physician's orders. Subsequent assessments and ADL flow sheets indicated that the resident was frequently incontinent of urine. However, a review of the clinical record revealed that no care plan was developed to address the resident's urinary incontinence. An interview with the Director of Nurses confirmed that a comprehensive care plan should have been created once the resident's incontinence was identified. The facility's care plan policy mandates the development of a patient-specific care plan to meet the resident's needs, which was not adhered to in this case.
Failure to Conduct Continence Assessment Post-Catheter Removal
Penalty
Summary
The facility failed to ensure a proper assessment for continence was completed for a resident after the discontinuation of an indwelling urinary catheter. The resident, who had a diagnosis of urine retention and benign prostatic hyperplasia, was identified as having severe cognitive impairment and requiring extensive assistance with activities of daily living. A physician's order directed the discontinuation of the indwelling urinary catheter, but the clinical record did not show that a bladder assessment was conducted to evaluate the resident's continence status post-catheter removal. Subsequent assessments and flow sheets indicated that the resident was frequently incontinent of urine. An interview with the Director of Nurses confirmed that a bowel and bladder assessment should have been completed following the catheter's removal, as per the facility's bowel and bladder management program policy.
Failure to Address and Document Resident Behaviors Leads to Fall
Penalty
Summary
The facility failed to adequately address and document the behaviors of a resident diagnosed with dementia and anxiety, leading to an incident where the resident fell and sustained a head injury. The resident, who was severely cognitively impaired and required extensive assistance, exhibited increased agitation and restlessness, which were not effectively managed. Despite a physician's order to administer Trazodone for anxiety and agitation, the medication was ineffective, and the staff did not notify the physician or take further action to address the resident's continued agitation. On the day of the incident, the resident was observed to be agitated, self-propelling in a wheelchair, and calling out for a spouse. The Trazodone administered by an LPN was ineffective, and the resident continued to exhibit agitated behaviors. The LPN did not report the ineffectiveness of the medication to the supervisor or seek further intervention, as she was occupied with other tasks. Consequently, the resident fell from the wheelchair, resulting in a laceration to the forehead and requiring hospital evaluation. Additionally, the facility failed to document the resident's behaviors consistently, as required by the physician's order. The behavior monitoring flow sheets did not reflect the resident's agitation and restlessness, particularly during the night shift, despite the administration of Trazodone on several occasions. This lack of documentation and communication contributed to the inadequate management of the resident's behaviors and the subsequent fall.
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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 Wallingford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skyview Rehab And Nursing | 0.6 mi | ★★★★★ | 22 | 0 |
| Regency House Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Elim Park Baptist Home, Inc | 3.4 mi | ★★★★★ | 0 | 0 |
| Complete Care At Meriden | 4.5 mi | ★★★★★ | 13 | 0 |
| Silver Springs Care Center | 4.8 mi | ★★★★★ | 4 | 0 |
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