Mason Health Care Center: Blood Sugar Failures - IN
That is what federal inspectors found when they visited Mason Health Care Center on August 26, 2025, following a complaint.
The numbers tell a straightforward story. From April 2 through April 18, the resident's blood sugar readings ranged from 112 to 313. Then on April 19, the readings were 329 at 4:38 in the morning, 320 at 11:36 in the morning, and 323 at 4:03 in the afternoon. Three readings in a single day, all above 300, none of them prompting documented physician contact.
The next day was worse. On April 20, the blood glucose level was 319 at 7:13 in the morning. By 11:01 in the morning it had climbed to 352. By 4:25 in the afternoon it reached 397.
Progress notes from April 18 and April 19 lacked any documentation that a physician had been notified of the abnormal levels.
When inspectors interviewed LPN 11 on the morning of August 26, the nurse described what the process was supposed to look like. If a resident had a high blood glucose level, she said, she would call the nurse practitioner to get orders and go from there. If the resident had no insulin orders, she would call the nurse practitioner, put it in the progress notes, and let the Director of Nursing and the Assistant Director of Nursing know.
That is the process as she described it. The progress notes show something different happened.
The Director of Nursing, interviewed the same morning, was direct about what should have occurred. The physician should have been notified of the elevated blood glucose levels, she said, and a progress note should have been completed at the time of the notification.
It was not.
The facility's own policy, titled Following Physician Orders/Parameters and provided to inspectors by the administrator on August 25, states that its purpose is to administer resident care in a safe and effective manner by following physician orders and ordered parameters, and that licensed healthcare personnel will consult and follow the physician or clinician order when performing any resident procedures.
The gap between that policy and what the progress notes actually show is what inspectors cited.
CMS rated the deficiency as causing minimal harm or potential for actual harm. Few residents were affected, according to the inspection record.
What the record does not show is whether anyone ever reached the physician during those two days, or what, if anything, was done as the readings climbed from 329 to 352 to 397. The documentation that would answer those questions does not appear to exist. A blood sugar of 397 in an elderly nursing home resident is not a borderline number. The absence of any documented response to readings at that level, across two consecutive days, is what the inspectors traveled to Warsaw to investigate, and what they found when they got there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mason Health Care Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
MASON HEALTH CARE CENTER in WARSAW, IN was cited for violations during a health inspection on August 26, 2025.
That is what federal inspectors found when they visited Mason Health Care Center on August 26, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.