Masonicare at Bishop Wicke Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Masonicare at Bishop Wicke Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF692Apr 17, 2026

  Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for nutrition, the facility failed to ensure adequate nutritional status and timely identification and response to significant weight loss. This included failure to accurately monitor and evaluate weight changes, obtain a timely re-weight to confirm a significant weight loss, recognize and act upon poor oral intake, notify the physician and Registered Dietitian (RD), implement nutritional interventions, and respond to family concerns. These failures resulted in a significant, unaddressed weight loss and severe malnutrition requiring hospitalization and clinical intervention. […]

• Actual harm, isolatedF689Jul 24, 2024

  Based on the clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was properly positioned prior to the provision of care resulting in a fall out of bed. The resident sustained a fractured ankle. The finding includes: Resident #1 was admitted with diagnoses that included Alzheimers disease, osteoarthritis, and abnormalities of mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, height was 67 inches, weight 181 pounds, and required maximum staff assistance with bed mobility. The Resident Care Plan (RCP) dated 6/28/2024 identified Resident #1 had decreased mobility and was at risk for falls. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2024

  Based on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure food items were dated and labeled, the kitchen was in clean and sanitary condition, and adequately store a chemical solution. The findings include: Tour of the Dietary Department on 2/14/24 at 11:00 AM and 2/20/24 at 9:55 AM with the Operations Manager identified the following: a. The kitchen floor was observed throughout the entirety of the kitchen with debris and food on the floor (including under the storage racks). b. Dust and debris was observed on the ice machine vents with dried stains going down the side of the ice machine. Additionally, black grime was observed on a metal bar, located beneath the ice machine lid, adjacent to the front panel. c. […]

• No harm, potential for more than minimal, patternF806Sep 17, 2025

  Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #58) reviewed for food choices, the facility failed to provide the correct diet. The findings include:Resident #58's diagnoses included hypertension, gastro-esophageal reflux disease (GERD), and gout.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status score of 14 indicating intact cognition, was dependent with personal hygiene, rolling left and right and with chair/bed-to-chair transfers, and required set-up assistance with eating. A signed Physician order dated 2/29/2024 identified Resident #58 had an allergy to garlic. […]

• No harm, potential for more than minimal, patternF812Sep 17, 2025

  Based on observations, interviews, and facility policy during a tour of the kitchen, the facility failed to ensure open food items were dated to include opened, expired, and used by dates, and failed to perform hand hygiene prior to placing gloves on during food preparation and food service. The findings include: 1. On 9/10/25 at 9:15 AM, during the initial brief kitchen tour and interview with the Food Service Director, identified in freezer #2, 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. […]