Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 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.
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.
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.
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 329 citations issued within 25 miles in the last 12 months — including the 2 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 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 | 2.4 mi | — | 4 | 1 |
| Apple Rehab Shelton Lakes | 2.4 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Masonicare At Bishop Wicke Health & Rehabilitation.
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.