Masonicare Health Center

In the surveyor’s words

From the most serious findings on record at Masonicare Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 19, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident environment remained as free of accident hazards as possible to ensure a resident with dementia and exit seeking behaviors did not have free access to a stairwell that resulted in a resident fall with polytrauma injuries which resulted in a hospital admission, and Resident #1 expired the following day. The failures resulted in a finding of Immediate Jeopardy for Resident #1. The findings include: The Administrator was notified of the Immediate Jeopardy on [DATE] at 3 PM. The immediate jeopardy was not removed by the exit date of the survey ([DATE]). […]

• Actual harm, isolatedF689Nov 13, 2024

  Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to properly transfer a resident which ultimately resulted in a fall with a laceration to the head and subdural hematoma. The findings include: Resident #1's diagnoses included dementia, difficulty walking, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a BIMS score of two (2) indicating short and long-term memory recall deficits and was dependent on staff for turning and repositioning when in bed and transfers getting in and out of the bed and chair. […]

• No harm, potential for more than minimal, widespreadF609Aug 6, 2026

  Based on staff interviews, review of the clinical record, facility documentation, and facility policy for 11 of 12 sampled residents (Resident #8, #17, #50, #53, #87, #97, #138, #234, #252, #254, and #255) reviewed for abuse, the facility failed to notify the State Agency in a timely manner of allegation of abuse/misappropriation of property. The findings include: 1.Resident #8 diagnoses included mixed anxiety and depression, difficulty in walking and muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 13 indicating intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. […]

• No harm, potential for more than minimal, widespreadF610Aug 6, 2026

  Based on interviews, clinical record review, facility documentation and review of facility policies for 11 of 11 sampled residents (Resident #8, #17, #50, #53, #87, #97, #138, #234, #252, #254, and #255) reviewed for missing personal property/allegations of abuse, the facility failed to thoroughly investigate potential misappropriation of property/abuse. The findings include: 1. Resident #8 diagnoses included mixed anxiety and depression, difficulty in walking and muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 13 indicating intact cognition, required set up for eating and partial/moderate assistance for dressing and changing positions in bed. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2026

  Based on tour of the Dietary Department, staff interview, and facility policy, the facility failed to ensure Dietary Aide (DA) #1 wore an appropriate hair covering and beard covering while serving food to residents. Findings include: Observation and interview with DA #1 on 7/31/26 at 12:17 PM identified he was opening/uncovering and serving food to residents without the benefit of a full hair covering and beard restraint. DA #1 had a cap on his head with several inches of exposed hair coming out from under the cap. DA #1 also had facial hair/beard not covered. […]