Mason Health Care Center: Resident Dies After Untreated UTI - IN
Inspectors cited Mason Health Care Center following a complaint investigation completed August 26, 2025. The resident, identified in the report only as Resident B, had an indwelling Foley catheter and repeatedly requested Pyridium, a medication for urethral pain. Nursing notes logged those requests at 7:14 p.m., 10:25 p.m., 2:33 p.m., and 10:32 a.m. across multiple dates. The clinical record contained no documentation that a physician was ever notified of the continued pain during the period from April 18 onward.
He was eventually transferred to the emergency room for a change in condition.
What the ER found was extensive. His temperature was 100.2 degrees. His blood pressure had dropped to 91 over 59. His heart rate was 120. A urinalysis showed 41 to 99 white blood cells, 11 to 40 red blood cells, and a high concentration of bacteria, consistent with a urinary infection. Imaging showed a marked increase in active pneumonia, possible fluid in the lungs, acute inflammation of the small intestine, and bladder wall thickening. Doctors suspected catheter dysfunction.
Emergency department discharge instructions, timestamped at 12:52 a.m., noted that Resident B had expired.
After his death, inspectors asked the facility for documentation of his urine output during the relevant period. The facility said it could not provide those records. Staff acknowledged there should have been documentation for any resident with a Foley catheter.
The Corporate Nurse told inspectors the facility had no policy for obtaining and documenting urine outputs for residents with urinary catheters.
Resident B had a recent stroke and had been experiencing episodes of stopped breathing before his hospitalization. He went to the emergency room with sepsis, a potentially fatal infection that can develop when an untreated urinary infection spreads. The Director of Nursing confirmed he still had the Foley catheter in place when he was transferred.
He asked for help with the pain. The notes show that. What the notes do not show is anyone answering.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
MASON HEALTH CARE CENTER in WARSAW, IN was cited for violations during a health inspection on August 26, 2025.
Inspectors cited Mason Health Care Center following a complaint investigation completed August 26, 2025.
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.