Mason Health Care Center: Catheter Failures Before Death - IN
Inspectors cited Mason Health Care Center following a complaint investigation, finding the facility had failed to notify the physician of Resident B's continued urethral pain across multiple days, and that staff had no documentation of his urine output during the period he had an indwelling catheter.
The clinical record told the story in pieces. A nursing note recorded that Resident B had urinary pain and had been given Pyridium, a medication used to relieve urinary tract discomfort. By that evening, he was asking for it again. He asked again at 10:25 that night. Notes over the following days recorded more requests for the same medication, more urinary pain, and continued use of the catheter. Other notes, logged around the same period, described urine as clear with no change in output, as though nothing was wrong.
At one point, the catheter was discontinued because it had become soiled and dislodged. A new catheter was placed. Notes returned to the same language: no change in urine output, clear urine, catheter draining to gravity.
What the record did not contain, inspectors found, was any documentation showing the physician was ever told about the ongoing pain. From April 18 through the date of transfer, there was no notation that a nurse had picked up the phone.
When Resident B reached the emergency department, the picture that emerged was severe. His temperature was 100.2 degrees. His blood pressure, at 91 over 59, indicated his body was struggling to maintain circulation. His heart was beating at 120 times per minute. A urinalysis came back showing 41 to 99 white blood cells, 11 to 40 red blood cells, and a heavy bacterial load, findings consistent with a urinary tract infection that had progressed. The ER documentation listed his chief complaint as a sepsis alert.
Later that afternoon, additional emergency documentation recorded what imaging and examination had found: marked worsening of active pneumonia in the lungs, possible pulmonary edema, acute inflammation of the small intestine, low-grade inflammation of the colon, and thickening of the bladder wall. Inspectors noted a specific line in the ER record: catheter dysfunction was suspected, with residual urine present despite the Foley catheter being in place.
The ER discharge instructions were timestamped at 12:52 in the morning. They documented that Resident B had expired.
When inspectors requested documentation of Resident B's urine output for the period in question, the facility said it could not provide it. A staff member acknowledged that urine output should have been tracked for any resident with a catheter in place.
The Corporate Nurse, interviewed the same afternoon, said the facility did not have a policy for obtaining and documenting urine output in residents with urinary catheters.
That admission is its own finding. Catheter-associated urinary tract infections are among the most preventable complications in long-term care. Monitoring output, watching for signs of blockage or infection, and communicating changes to a physician are the basic mechanisms by which those infections get caught before they become systemic. At Mason Health Care Center, none of those mechanisms were formalized in writing, and the records suggest they weren't happening in practice either.
The Director of Nursing confirmed during the inspection that Resident B still had an indwelling Foley catheter when he was transferred to the hospital.
What the record cannot answer is whether earlier intervention would have changed the outcome. Sepsis can move fast, and by the time Resident B reached the emergency room, he was already in crisis. But the pattern documented in the nursing notes, days of pain, repeated requests for the same medication, no physician notification, no output tracking, and a catheter that may have stopped functioning, was a pattern that staff had the information to see and did not act on.
CMS rated the violation as causing minimal harm or potential for actual harm. Resident B did not survive his transfer.
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 immediate jeopardy violations during a health inspection on August 26, 2025.
The clinical record told the story in pieces.
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.