Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Mason Health Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to ensure privacy during incontinence care for three residents with dementia, Alzheimer’s disease, overactive bladder, and other neurologic conditions. Two CNAs provided incontinence care to a resident with intracerebral hemorrhage and altered mental status without pulling the privacy curtain between the resident and a roommate. Two other residents with severe cognitive impairment and documented bladder/bowel incontinence received incontinence care while privacy curtains between them and their roommates were not used and, in some instances, window blinds remained open, leaving a window exposed. A CNA acknowledged that curtains and blinds should have been closed, and facility policy stated residents have a right to be treated with respect and dignity.
Staff did not consistently change gloves between soiled incontinence/peri care and application of clean briefs for three residents with dementia, cognitive impairment, and bowel/bladder incontinence. In multiple observed episodes, CNAs removed soiled briefs, performed peri care with disposable wipes, and then, without changing gloves or performing hand hygiene, applied clean incontinence briefs. One affected resident did not yet have an incontinence care plan in place, while others had documented incontinence and required substantial or total assistance with toileting hygiene.
The facility did not notify the physician or NP of significantly elevated blood glucose levels for two residents with diabetes, despite physician orders and facility policy requiring such notification. Blood glucose readings above the specified threshold were not reported, and there was no documentation in the progress notes to indicate that the provider was informed, as confirmed by staff interviews.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
A resident with a gastrostomy tube did not have physician orders or documentation for required water flushes before and after medication administration, nor for insertion site care, despite facility policies and care plan directives. Nursing staff confirmed these orders and care should have been in place, resulting in a deficiency for inadequate feeding tube care.
A resident with complex medical conditions did not receive scheduled pain medication timely due to communication issues with an RN. The resident's pain medication, Norco, was often administered late, exceeding the facility's policy of a one-hour window. Despite the resident and her daughter addressing the issue, the RN failed to ensure timely administration, leading to increased pain levels for the resident.
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, affecting all residents consuming food. Observations revealed improperly stored and expired food items, and staff handling food without gloves. Microwaves in pantries contained dried food debris, violating the facility's food safety policies.
A facility failed to update a resident's activity care plan to reflect their current preferences and needs. The resident, with multiple health conditions, expressed a desire for activities like listening to music and participating in religious activities, but the care plan included irrelevant interventions. Despite an updated activity assessment, the care plan was not revised, leading to a deficiency.
A facility failed to provide appropriate communication devices for a Spanish-speaking resident with cognitive deficits and multiple medical conditions. Despite a care plan indicating the need for translation services, staff were not adequately equipped to communicate with the resident, and a Spanish communication board was not available as required. Observations showed the resident frequently yelling in Spanish, with staff using ineffective ad-hoc methods for communication.
A facility failed to change a resident's respiratory equipment as per physician orders. Observations showed that the oxygen tubing and humidification bottle, dated 8/18/2024, were not changed weekly as required, and the humidification bottle was empty. The resident, with a history of COPD, was receiving oxygen at 2 liters per minute. The facility's policy and physician orders required weekly changes, which were not followed, as confirmed by an LPN.
The facility failed to ensure proper medication storage and handling, with unlocked medication carts, inappropriate items stored with medications, expired medications, and improper labeling. Additionally, a medication room refrigerator had significant ice build-up and was consistently below the appropriate temperature range. Staff interviews confirmed these practices did not align with facility policies.
A facility failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for a resident with a neurogenic bladder and ESBL infection. A QMA was observed performing this task without a face shield or gown, contrary to the facility's Enhanced Barrier Precautions policy, which requires such PPE during high-contact care activities.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The deficiency involves failure to provide privacy during incontinence care for three residents during early morning care. For Resident B, surveyors observed two CNAs providing incontinence care without pulling the privacy curtain between the resident and his roommate. Resident B’s diagnoses included nontraumatic intracerebral hemorrhage, dementia, and altered mental status. At the time of the survey, an admission MDS was in progress and Resident B did not yet have a care plan addressing incontinence care. For Resident C, two CNAs assisted with placement of an incontinence brief while the resident was in bed. One CNA pulled the resident’s lower garment to her ankles and placed the brief underneath her without pulling the privacy curtain between her and her roommate or closing the window blinds. Resident C had Alzheimer’s disease, dementia, and overactive bladder, with an MDS indicating severe cognitive impairment and a need for substantial assistance with toileting hygiene; her care plan documented intermittent incontinence and the need for assistance with incontinence care. For Resident D, two CNAs provided incontinence care with the privacy curtain by the window only partially pulled, leaving an exposed window with open blinds, and the curtain between the resident and her roommate not pulled. Resident D had spastic hemiplegia, cerebral infarction, and overactive bladder, with an MDS indicating severe cognitive impairment and total dependence for toileting hygiene; her care plan documented bladder and bowel incontinence and staff assistance with incontinence care. During interview, one CNA acknowledged that privacy curtains and window blinds should have been closed during incontinence care. The facility’s Resident Rights policy stated that residents have the right to be treated with respect and dignity.
Failure to Change Gloves Between Soiled and Clean Incontinence Care
Penalty
Summary
Staff failed to change gloves between providing soiled incontinence/perineal care and applying clean incontinence briefs for multiple residents. During an early morning observation, two CNAs assisted a resident with dementia and altered mental status who was incontinent of urine in bed. After removing the soiled brief and performing peri care with disposable wipes, one CNA did not change gloves before helping apply a clean brief. This resident’s admission MDS was still in progress and there was no care plan addressing incontinence care at the time of review. In separate observations, another resident with Alzheimer’s disease, dementia, overactive bladder, severe cognitive impairment, and a care plan for intermittent bowel and bladder incontinence received peri care while sitting on the edge of the bed; the assisting CNA did not change gloves before placing a clean brief. A third resident with spastic hemiplegia, cerebral infarction, overactive bladder, severe cognitive impairment, and total incontinence of bowel and bladder was provided incontinent peri care by a CNA who then neither washed hands nor changed gloves before applying a clean brief. The CNA later stated that gloves should have been changed after providing incontinence care and before placing clean briefs. The facility’s incontinence policy stated that incontinent residents would receive appropriate treatment and services, including treatment to prevent infections.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for two residents with diabetes, as required by physician orders. For one resident with type 2 diabetes, blood glucose readings exceeded the ordered notification threshold of 400 mg/dl on multiple occasions, specifically with values of 443 mg/dl, 546 mg/dl, and 436 mg/dl, without documentation that the physician or Nurse Practitioner was notified. Interviews with nursing staff and the Director of Nursing confirmed that the protocol was to notify the provider and document the notification in the progress notes, which was not done in these instances. Another resident with multiple diagnoses, including type 2 diabetes and acute kidney failure, had several blood glucose readings ranging from 319 mg/dl to 397 mg/dl over two days. Despite facility policy and staff statements indicating that elevated blood glucose levels should prompt notification of the physician and documentation in the progress notes, there was no evidence in the resident's record that the physician was notified of these abnormal results. The facility's policy required following physician orders and parameters, but this was not adhered to in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Ensure Proper Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to provide appropriate feeding tube care for one resident who was cognitively intact and had a history of cerebral infarction, dysphagia, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a gastrostomy tube for artificial nutrition and hydration, with a care plan indicating the need for site care and water flushes as ordered. However, a review of physician orders revealed there were no orders for water flushes before and after medication administration, nor for gastrostomy site care. Documentation was also lacking regarding water flushes and insertion site dressing changes. During interviews, nursing staff confirmed that residents should have orders for both medication flushes and insertion site care. Facility policies required staff to follow protocols for flushing feeding tubes before and after feedings and medications, and to perform daily or as-needed gastrostomy site care per physician order and professional standards. Despite these policies, the required orders and documentation were not present for the resident in question, resulting in a deficiency related to feeding tube care.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide scheduled pain medication in a timely manner for a resident, identified as Resident B, who was reviewed for pharmaceutical services. Resident B, who was cognitively intact and had complex medical conditions including leukemia, anemia, and anxiety disorder, had a physician's order for Norco to be administered every four hours for pain management. However, the Medication Administration Audit Report revealed multiple instances where the medication was administered significantly later than the scheduled times, often exceeding the facility's policy of administering medication within an hour before or after the scheduled time. Resident B expressed that her pain level increased if she waited more than 40 minutes past the scheduled administration time, and she had to wake up during the night to ensure she received her medication. The issue was compounded by a communication problem involving RN 2, who was responsible for informing other nursing staff to administer the medication during his shifts but failed to do so. Despite Resident B and her daughter addressing the issue with RN 2, he did not take responsibility for ensuring timely medication administration, leading to the deficiency.
Sanitation and Food Handling Deficiencies in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, as observed during a survey. In the kitchen, black specs were found on a shelf in the walk-in cooler, and several food items, including tater tots and diced pepperoni, were improperly stored without dates or seals. Additionally, expired spices were found on a kitchen shelf. During meal observations, staff members were seen handling food improperly; CNAs passed lunch trays with fingers over the rims of plates and handled a dinner roll with bare hands, contrary to the facility's policy requiring gloves for ready-to-eat foods. Further observations revealed unsanitary conditions in the nutrition pantries, where microwaves contained dried food debris. The facility's policies on food safety, including proper labeling, dating, and handling of food, were not adhered to, as evidenced by the undated and improperly sealed food items and the lack of glove use when handling ready-to-eat foods. These deficiencies had the potential to affect all residents consuming food from the kitchen and pantries.
Failure to Update Resident's Activity Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised and updated in accordance with the resident's current needs and preferences. The resident, who has multiple diagnoses including hemiplegia, dysphagia, and chronic kidney disease, expressed specific preferences for activities such as listening to music, being around pets, and participating in religious activities. However, the care plan, which was last updated in July 2023, did not reflect these preferences accurately. Instead, it included interventions that were not aligned with the resident's stated interests, such as providing magazines and crosswords, which the resident indicated were not very important. The deficiency was identified during a record review and interview process. The facility's policy requires care plans to be reviewed and revised as necessary when a resident experiences a status change. Despite an activity assessment update in June 2024, which noted the resident's participation in sensory club and acceptance of pet visits, the care plan was not updated to reflect these changes. The Activities Director was responsible for updating the care plan but failed to do so, leading to a discrepancy between the resident's current needs and the documented care plan.
Failure to Provide Communication Devices for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication devices for a Spanish-speaking resident, identified as Resident 29, who was reviewed for communication needs. Resident 29 had a medical history that included hemiplegia, hemiparesis, anxiety disorder, dysphagia, and major depressive disorder. The resident's care plan indicated that her primary language was Spanish and that she required a translator at times. Despite these documented needs, the facility did not ensure the availability of a communication board or other effective communication tools for Resident 29. Observations revealed that Resident 29 was frequently yelling out in Spanish, and staff members, including a housekeeper and a Qualified Medication Aide (QMA), were not adequately equipped to communicate with her. The staff relied on ad-hoc methods such as using Google Translate or asking Spanish-speaking staff members to assist, which were not consistently effective. Interviews with staff members, including the Executive Director and Registered Nurses (RNs), revealed a lack of awareness and availability of the Spanish communication board, which was supposed to be accessible at the nursing station. The Executive Director mentioned that an in-service training on the Spanish communication board had been conducted, but housekeeping staff were not in attendance, and the communication board was not found at the designated location. The facility's policy on communicating with persons with Limited English Proficiency (LEP) outlined the need for meaningful communication and the use of language assistance services, but these measures were not effectively implemented for Resident 29.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to ensure that respiratory equipment was changed according to physician orders for a resident using oxygen. Observations on multiple dates revealed that the oxygen tubing and humidification bottle for a resident were not changed weekly as required. Specifically, the oxygen tubing and humidification bottle were dated 8/18/2024 and remained unchanged and empty during observations on 8/26/2024, 8/28/2024, and 8/29/2024. The resident's physician orders, dated 5/28/2024, specified that the oxygen tubing and supplies should be changed weekly, every night shift on Sunday. The resident in question had a history of paraplegia, malnutrition, depression, and asthma, and was receiving oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (COPD). The care plan indicated that the resident should receive oxygen as ordered and that the oxygen tubing should be changed weekly. However, the Treatment Administration Record (TAR) showed that the oxygen tubing and water bottle had not been changed since 8/18/2024. An interview with an LPN confirmed that the tubing had not been changed and the humidification bottle should not have been empty. The facility's policy required changing the oxygen tubing and mask/cannula weekly and the humidifier bottle when empty or weekly, which was not adhered to in this case.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and handling across four medication storage areas. Observations revealed that a medication cart on the 400 hall was left unlocked when not in use, as a QMA walked away from it, and an LPN passed by it twice without securing it. Additionally, the 300 hall medication cart contained inappropriate items, such as a bottle of shampoo and an expired container of skin cream. The 100 hall medication cart had an opened and undated bottle of Miralax, indicating a lack of proper labeling and dating of medications. Furthermore, the medication room on the 100 hall had a refrigerator with a significant ice build-up in the freezer section, and the temperature log indicated that the refrigerator's temperature was consistently below the appropriate range on several dates. The facility's policies on medication storage and drug disposition were not adhered to, as evidenced by the presence of expired and improperly stored medications. Interviews with staff confirmed these deficiencies, acknowledging that the observed practices did not align with the facility's policies.
Failure to Use Appropriate PPE During Catheter Care
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) when emptying a Foley catheter drainage bag for a resident. During an observation, a Qualified Medication Aide (QMA) was seen emptying the urine drainage bag of a resident without wearing a face shield or gown, which are required under the facility's Enhanced Barrier Precautions policy. The resident in question had a Foley catheter due to a neurogenic bladder and was on enhanced barrier precautions due to an extended-spectrum beta-lactamase (ESBL) infection in the urine. The resident's medical history included paraplegia, malnutrition, depression, and neuromuscular dysfunction of the bladder. The facility's policy, provided by the Director of Nursing, indicated that enhanced barrier precautions require the use of gowns and gloves during high-contact care activities, such as device care involving urinary catheters. The QMA was unaware of the need for a gown and face shield, indicating a lapse in adherence to the infection control policy.
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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 Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paddock Springs | 1.6 mi | — | 4 | 0 |
| Warsaw Meadows | 1.8 mi | — | 16 | 0 |
| Grace Village Health Care Facility | 2.1 mi | — | 0 | 0 |
| Miller's Merry Manor | 2.6 mi | — | 0 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 12.4 mi | — | 0 | 0 |
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