Inspection Reports for
Mason Health Care Center
900 PROVIDENT DRIVE, WARSAW, IN, 46580
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
25.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
507% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to notify physicians of significantly elevated blood glucose levels and failure to monitor urine outputs for residents with indwelling catheters.
Complaint Details
The complaint investigation substantiated that the facility did not notify physicians of elevated blood glucose levels and failed to monitor urine outputs for residents with catheters. Resident B experienced urethral pain, urinary infection, and was hospitalized with sepsis before expiring. The facility lacked policies and documentation for urine output monitoring.
Findings
The facility failed to notify the physician or Nurse Practitioner of elevated blood glucose levels for 2 of 3 residents reviewed and failed to ensure urine outputs were monitored for a resident with an indwelling catheter. Documentation of physician notification and urine output was lacking, contributing to adverse resident outcomes.
Deficiencies (2)
F 0684: The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for 2 of 3 residents reviewed. Documentation showed multiple instances of blood glucose levels above 400 mg/dl without notification.
F 0690: The facility failed to ensure urine outputs were monitored for a resident with an indwelling catheter. Documentation was incomplete, and the resident experienced urinary pain and infection, ultimately leading to hospitalization and death.
Report Facts
Blood glucose levels: 443
Blood glucose levels: 546
Blood glucose levels: 436
Urine output: 250
Urine output: 600
Organisms count: 10000
Temperature: 100.2
Blood pressure: 91
Blood pressure: 59
Heart rate: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Interviewed regarding notification of elevated blood glucose levels | |
| Director of Nursing | Interviewed regarding notification of elevated blood glucose levels and urine output monitoring | |
| LPN 11 | Interviewed regarding procedure for notifying Nurse Practitioner of high blood glucose levels | |
| Administrator | Provided facility policy on following physician orders | |
| Corporate Nurse | Interviewed regarding lack of policy on urine output documentation |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 26, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with healthcare regulations and standards at Mason Health Care Center.
Findings
The facility was found deficient in multiple areas including unnecessary use of psychotropic medications, incomplete care plans for diabetic monitoring, inadequate assistance with activities of daily living, failure to notify physicians of elevated blood glucose levels, delayed hearing aid referrals, incomplete narcotic inventory documentation, medication administration errors, improper storage and disposal of medications, unsanitary food storage and preparation practices, and lapses in infection control during wound care.
Deficiencies (10)
F 0605: The facility failed to ensure appropriate medical symptoms supported the use of an antipsychotic for 1 of 5 residents reviewed for unnecessary medications.
F 0656: The care plan did not address a diabetic resident's refusal of blood glucose monitoring for 1 of 1 residents reviewed.
F 0677: The facility failed to provide assistance with showering as per care plan for 1 of 2 residents reviewed for ADL care.
F 0684: The facility failed to notify the physician for significantly elevated blood glucose levels for 2 of 3 residents reviewed.
F 0685: The facility failed to ensure timely follow-up on audiologist recommendations for hearing aids for 1 of 3 residents reviewed.
F 0755: The narcotic inventory book was incomplete with 8 missing signatures out of 72 opportunities on 1 of 2 medication carts.
F 0759: Medication administration errors occurred in 5 of 30 opportunities, resulting in a 16.67% error rate including missed doses and use of expired insulin.
F 0761: The facility failed to secure and properly dispose of discontinued controlled medications and expired medications in medication carts and storage room.
F 0812: Foods were stored, prepared, and served in an unsanitary manner in the kitchen, including unsealed containers, greasy steam tables, and dirty dishes.
F 0880: Staff failed to follow infection control practices during a skin treatment, including improper hand hygiene and lack of barrier use.
Report Facts
Medication administration error rate: 16.67
Narcotic inventory signatures missing: 8
Medication cart narcotic count: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 5 | Interviewed regarding narcotic inventory signatures and medication administration | |
| Director of Nursing | Interviewed regarding medication use, care planning, and notification of elevated blood glucose levels | |
| Executive Director | Provided policies on controlled substances, insulin administration, and medication destruction | |
| LPN 4 | Observed performing wound treatment with infection control lapses | |
| RN 2 | Observed administering medications and interviewed about medication errors | |
| Social Service Director | Interviewed regarding hearing aid referral for Resident 3 | |
| RN 6 | Interviewed regarding insulin vial expiration and medication administration | |
| QMA 7 | Interviewed regarding insulin vial expiration and medication administration | |
| Dietary Manager | Interviewed regarding food storage and kitchen sanitation issues | |
| Registered Dietician | Interviewed regarding steam table cleaning practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Indiana Department of Health on 2025-06-11 regarding inadequate feeding tube care at the facility.
Complaint Details
The complaint was received on 2025-06-11 and included allegations that cleaning had not been performed around the feeding tube and only a gauze pad had been placed. The citation relates to Complaint IN00461321.
Findings
The facility failed to ensure appropriate feeding tube care for 1 of 3 residents reviewed, specifically lacking water flushes before and after medication administration and insertion site care for the feeding tube. Policies exist but were not followed, and no physician orders or documentation supported proper care.
Deficiencies (1)
F 0693: The facility failed to ensure appropriate feeding tube care was provided regarding water flushes before and after medication administration and insertion site care for 1 of 3 residents reviewed for tube feeding.
Report Facts
Residents reviewed for tube feeding: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Interviewed regarding feeding tube care and orders | |
| Executive Director | Provided facility policies on feeding tube flushing and gastronomy site care |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461321 regarding allegations of inadequate feeding tube care at Mason Health Care Center.
Complaint Details
Complaint IN00461321 was received by the Indiana Department of Health on 6/11/2025 alleging inadequate cleaning around the feeding tube and improper dressing placement. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to ensure appropriate feeding tube care for 1 of 3 residents reviewed, specifically Resident F, including lack of water flushes before and after medication administration and absence of insertion site care orders. The facility nursing staff was reinstructed on policies and procedures, and monitoring plans were established to ensure compliance.
Deficiencies (1)
Failed to ensure appropriate feeding tube care regarding water flushes before and after medication administration and insertion site care for 1 of 3 residents reviewed (Resident F).
Report Facts
Census: 68
Total Capacity: 68
Medicare Residents: 6
Medicaid Residents: 44
Other Payor Residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 2 | Interviewed on 6/17/2025 regarding feeding tube care orders |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a Paper Compliance Review related to the Investigation of Complaints IN00454167 completed on March 5, 2025.
Complaint Details
Complaint Investigation IN00454167 was reviewed and found to be in compliance.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the timely administration of pain medication to Resident B at Mason Health Care Center.
Complaint Details
This citation relates to Complaint IN00454167. The complaint involved delayed administration of pain medication to Resident B, which was substantiated by interviews and medication audit reports.
Findings
The facility failed to provide scheduled pain medication in a timely manner for Resident B due to communication issues among nursing staff. Medication administration audit reports showed multiple instances of delayed pain medication beyond the scheduled times.
Deficiencies (1)
F 0684: The facility failed to provide scheduled pain medication in a timely manner for 1 of 3 residents reviewed. Resident B experienced delays in receiving Norco pain medication, with administration times often exceeding one hour past the scheduled time.
Report Facts
Medication administration delays: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in findings related to failure to administer or communicate timely administration of Resident B's pain medication. |
| RN 3 | Registered Nurse | Interviewed regarding communication problems with RN 2 about medication administration. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
This visit was for the investigation of Complaint IN00454167 related to allegations of deficiencies in medication administration at Mason Health Care Center.
Complaint Details
Complaint IN00454167 was substantiated with federal/state deficiencies cited at F684 related to delayed administration of pain medication to Resident B. Resident B and family reported communication issues with nursing staff, specifically RN 2, who did not inform other staff to administer medications timely. Facility policy requires medication administration within 60 minutes before or after scheduled time.
Findings
The facility failed to provide scheduled pain medication in a timely manner for 1 of 3 residents reviewed (Resident B). The investigation found delays in administering pain medication beyond the facility's policy of within 60 minutes before or after the scheduled time, affecting Resident B's pain management.
Deficiencies (1)
Failure to provide scheduled pain medication in a timely manner for Resident B.
Report Facts
Census: 73
Total Capacity: 73
Medicare Residents: 7
Medicaid Residents: 50
Other Payor Residents: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 2 | Named in findings related to failure to communicate and timely administer Resident B's pain medication | |
| RN 3 | Interviewed regarding communication problems with RN 2 about medication administration |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Jan 25, 2025
Visit Reason
This visit was conducted to investigate two complaints, IN00443764 and IN00451428, regarding the facility.
Complaint Details
Investigation of Complaint IN00443764 and Complaint IN00451428 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 5
Medicaid Census: 48
Other Payor Census: 24
Inspection Report
Follow-Up
Census: 79
Capacity: 105
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 09/17/24.
Findings
At this PSR survey, Mason Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Certified beds: 105
Census: 79
Inspection Report
Life Safety
Census: 68
Capacity: 105
Deficiencies: 21
Date: Sep 17, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness, means of egress, fire alarm system maintenance, sprinkler system installation and maintenance, portable fire extinguisher placement, electrical safety, and fire drills. Deficiencies affected residents, staff, and visitors with corrective actions planned or underway.
Deficiencies (21)
Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment and strategies for addressing emergency events.
Failed to ensure emergency preparedness plan addressed resident population, including persons at-risk and continuity of operations.
Failed to include process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials.
Failed to ensure emergency preparedness communication plan included primary and alternate means for communication with staff and emergency agencies.
Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to ensure emergency generator had a reliable source of fuel with proper documentation.
Means of egress through 5 exit doors were not readily accessible; doors were magnetically locked with codes not clearly understood by residents and visitors.
Failed to maintain headroom clearance in activity dining rooms due to hanging light fixtures below required height.
Failed to provide approved method for returning cooking appliances to approved design location after maintenance or cleaning.
Failed to maintain kitchen extinguishing system with remote pull station mounted too high above floor.
Fire alarm system had a trouble signal due to faulty sprinkler sensor that was not corrected at time of survey.
Fire control panel time was incorrect.
Sprinkler head in activity supplies closet was obstructed by supplies stacked too high.
Sprinkler heads in laundry room were covered with lint and not cleaned or replaced.
Two portable fire extinguishers in maintenance office were improperly placed on the floor.
Failed to ensure emergency generator had reliable fuel source documentation meeting regulatory requirements.
Electrical receptacles within 18 inches of sink in medication room lacked required GFCI protection.
Failed to conduct quarterly fire drills at varying times and conditions; drills clustered at end of month and similar times.
Used multi-plug adaptors and power strips improperly as substitutes for fixed wiring in resident rooms and staff areas.
Power strip used in patient care vicinity did not meet UL rating requirements.
Flexible cord used as substitute for fixed wiring powering microwave oven in staff pantry.
Report Facts
Facility capacity: 105
Census: 68
Fire drills conducted: 12
Exit doors with deficient egress: 5
Activity dining rooms with deficient headroom: 2
Sprinkler heads covered with lint: 2
Portable fire extinguishers improperly placed: 2
Power strips removed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named in multiple findings and exit conference |
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 6
Date: Aug 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 26 to August 30, 2024.
Findings
The facility was found deficient in multiple areas including care plan revisions, communication devices for non-English speaking residents, respiratory equipment maintenance, medication storage and security, food sanitation and safety, and infection prevention practices. Plans of correction were submitted for each deficiency with monitoring and re-education protocols.
Deficiencies (6)
Failed to ensure a care plan regarding activities was revised and updated for 1 of 21 residents reviewed (Resident 6).
Failed to provide appropriate communication devices for a Spanish speaking resident (Resident 29).
Failed to ensure respiratory equipment was changed per Physician orders for 1 resident reviewed for oxygen use (Resident 14).
Failed to ensure medication storage carts were locked when not in use; failed to store medications appropriately; failed to remove expired medications; and failed to ensure medication refrigerator freezer was free from ice buildup.
Failed to store, prepare and serve food in a sanitary manner in the kitchen and nutrition pantries, including unsealed and expired food items, and improper food handling by staff.
Failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for 1 resident reviewed for catheters (Resident 14).
Report Facts
Census: 72
Total Capacity: 72
Survey Dates: 5
Medicare Residents: 7
Medicaid Residents: 48
Other Payor Residents: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| QMA 12 | Observed emptying Foley catheter drainage bag without appropriate PPE | |
| RN 14 | Interviewed regarding communication with Resident 29 and Spanish communication board availability | |
| LPN 3 | Interviewed regarding oxygen tubing and medication storage deficiencies | |
| Director of Nursing | Provided multiple facility policies and interviewed regarding deficiencies | |
| Dietary Manager | Interviewed regarding food sanitation and safety deficiencies |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on August 30, 2024.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 30, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Mason Health Care Center.
Findings
The facility was found deficient in multiple areas including care plan updates, communication accommodations for Spanish-speaking residents, respiratory equipment maintenance, medication storage and security, food safety and sanitation, and infection control practices related to PPE use.
Deficiencies (6)
F 0657: The facility failed to revise and update the activity care plan for 1 of 21 residents reviewed, specifically Resident 6.
F 0676: The facility failed to provide appropriate communication devices for a Spanish-speaking resident (Resident 29), resulting in ineffective communication.
F 0695: The facility failed to ensure respiratory equipment was changed per physician orders for Resident 14, including oxygen tubing and humidification bottle.
F 0761: Medication storage carts were left unlocked, medications were stored improperly, expired medications were not removed, and ice buildup was present in medication refrigerator freezer sections.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner in the kitchen and nutrition pantries, including unsealed and expired food items and poor employee hygiene practices.
F 0880: The facility failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for Resident 14.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication storage areas observed: 4
Residents potentially affected: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 14 | Registered Nurse | Mentioned in respiratory care and communication deficiencies involving Resident 29 and Resident 14 |
| QMA 8 | Qualified Medication Aide | Observed leaving medication cart unlocked |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication storage and respiratory equipment deficiencies |
| Dietary Manager | Interviewed regarding food safety deficiencies | |
| QMA 12 | Qualified Medication Aide | Observed emptying Foley catheter drainage bag without appropriate PPE |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: May 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433810.
Complaint Details
Complaint IN00433810 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00433810 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 74
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430593 and IN00429946.
Complaint Details
Investigation of Complaints IN00430593 and IN00429946 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00430593 and IN00429946 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 11
Medicaid census: 49
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
This visit was for the investigation of complaints IN00426233 and IN00425270.
Complaint Details
Complaint IN00426233 - No deficiencies related to the allegations are cited. Complaint IN00425270 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00426233 and IN00425270 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 71
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of complaints IN00423083 and IN00423682 completed on December 28, 2023.
Complaint Details
The investigation was related to complaints IN00423083 and IN00423682 and was completed with the facility found in compliance.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to investigate complaints related to misappropriation of resident property and medication accountability issues at Mason Health Care Center.
Complaint Details
This citation relates to Complaint IN00423083 regarding misappropriation of resident property and Complaint IN00423682 regarding medication accountability.
Findings
The facility failed to complete thorough investigations for two allegations of misappropriation of resident property and lacked a process of accountability for medications awaiting final disposition for four residents. Investigations were inconclusive regarding theft, and medication packets were not properly labeled with disposition reasons.
Deficiencies (2)
F 0610: The facility failed to ensure thorough investigations were completed for misappropriation of resident property for 2 of 2 allegations reviewed. Investigations included camera reviews and staff interviews but were unable to confirm if money was stolen.
F 0755: The facility failed to have a process of accountability for medications awaiting final disposition for 4 of 8 residents reviewed. Medication packets were not labeled with disposition reasons as required by facility policy.
Report Facts
Missing money amount: 27
Missing money amount: 40
Residents with medication disposition issues: 4
Medication packets without disposition reason: 5
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 2
Date: Dec 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422660, IN00423083, and IN00423682 regarding allegations of misappropriation of resident property and pharmacy service deficiencies.
Complaint Details
Complaint IN00422660 - No deficiencies related to the allegations were cited. Complaint IN00423083 - Federal/state deficiencies related to misappropriation of resident property were cited at F610. Complaint IN00423682 - Federal/state deficiencies related to pharmacy services were cited at F755.
Findings
The facility failed to ensure thorough investigations were completed for allegations of misappropriation of resident property for two residents and failed to maintain proper accountability for medications awaiting final disposition for four residents. Some medication packets were not labeled with disposition reasons. The facility provided lock boxes to affected residents and initiated investigations but was unable to confirm theft in the cases reviewed.
Deficiencies (2)
Failed to ensure investigations were completed for misappropriation of resident property for 2 residents.
Failed to provide pharmaceutical services with accurate procedures for acquiring, receiving, dispensing, and administering drugs, including lack of accountability for medications awaiting final disposition for 4 residents.
Report Facts
Residents affected by misappropriation allegations: 2
Residents affected by medication disposition deficiencies: 4
Missing money reported for Resident B: 27
Missing money reported for Resident F: 40
Total census: 71
Total capacity: 71
Inspection Report
Life Safety
Census: 73
Capacity: 115
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code Survey, Mason Health Care Center was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
A Post Survey Revisit (PSR) of Complaint Number IN00415890 was conducted to verify compliance following a complaint investigation.
Complaint Details
Complaint Number IN00415890 was corrected as of the survey date.
Findings
At this PSR Complaint survey, Mason Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for two detached sheds used for storage.
Report Facts
Facility capacity: 115
Census: 81
Inspection Report
Life Safety
Census: 77
Capacity: 115
Deficiencies: 3
Date: Oct 2, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to protect a hazardous storage area, failure to replace or test sprinkler system gauges every 5 years, and failure to post required signage in the liquid oxygen transfilling room.
Deficiencies (3)
Failed to ensure the activity office storage room with combustible materials over 50 square feet was protected as a hazardous area; the corridor door did not self-close and latch.
Failed to ensure one of three sprinkler system gauges was replaced or tested every 5 years; one gauge was dated 2016 with no recalibration documentation.
Failed to ensure the liquid oxygen storage/transfer room was provided with a sign indicating that transferring is occurring and that smoking is prohibited.
Report Facts
Facility capacity: 115
Census: 77
Number of sprinkler system gauges: 3
Number of sprinkler system gauges not replaced/tested within 5 years: 1
Number of residents potentially affected by hazardous storage room deficiency: 10
Number of residents potentially affected by oxygen room signage deficiency: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Reviewed findings and exit conference |
| Director of Plant Operations | Interviewed and involved in observations and corrective actions |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 9
Date: Sep 22, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00417481) regarding concerns about resident dignity, privacy, abuse reporting, personal care, foot care, range of motion care, IV therapy management, staffing levels, and kitchen sanitation at Mason Health Care Center.
Complaint Details
Complaint IN00417481 triggered the inspection. The complaint involved concerns about resident dignity, privacy, abuse reporting, personal care, foot care, range of motion care, IV therapy management, staffing levels, and kitchen sanitation. The complaint was substantiated with findings of deficiencies in all these areas.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining assistance, privacy breaches, failure to report and investigate abuse allegations timely, inadequate response to personal care requests, lack of preventative foot care, insufficient contracture management, improper IV therapy maintenance and discontinuation, inadequate staffing levels, and poor kitchen sanitation practices.
Deficiencies (9)
F 0550: The facility failed to ensure dignity was maintained during dining assistance for 3 of 8 residents in the assisted dining room, with staff standing and leaning over residents instead of sitting at eye level.
F 0583: The facility failed to ensure privacy for 3 of 24 residents during observations, including unattended computer screens displaying personal information and staff entering rooms without knocking.
F 0609: The facility failed to timely report and investigate an allegation of abuse involving 2 residents, with the state agency not notified as of the survey date.
F 0677: The facility failed to respond to a request for positioning and personal care for 1 of 7 residents reviewed, resulting in a resident waiting over 30 minutes for assistance.
F 0687: The facility failed to develop and implement preventative foot care interventions for 1 resident with diabetes and history of toe amputation, resulting in untreated toenail infection and delayed podiatry referral.
F 0688: The facility failed to ensure individualized contracture management interventions for 1 resident with declining range of motion and spasticity, lacking restorative nursing program and monitoring.
F 0694: The facility failed to ensure intravenous therapy was properly maintained and discontinued for 1 resident, including missed antibiotic doses, lack of IV catheter measurement, and incomplete documentation.
F 0725: The facility failed to maintain adequate nursing and CNA staffing levels on multiple days in September 2023, impacting resident care including repositioning and personal care.
F 0812: The facility failed to ensure kitchen sanitation, with dirty pans, debris on floors and cabinetry, improperly stored food items without open dates, and poor hand hygiene practices by dietary staff.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 76
Census: 79
Staffing hours: 48
Staffing hours: 161
Staffing hours: 76
Staffing hours: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 5 | Qualified Medication Aide | Named in dignity failure during dining assistance |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity, abuse reporting, personal care, IV therapy, and contracture management findings |
| Administrator | Administrator | Interviewed regarding abuse reporting, staffing, and kitchen sanitation |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding privacy breach with computer screen |
| Physical Therapy Assistant 8 | Physical Therapy Assistant | Named in privacy breach for entering room without knocking |
| LPN 15 | Licensed Practical Nurse | Interviewed regarding podiatry consult request |
| Rehabilitation Director/Occupational Therapist | Rehabilitation Director/Occupational Therapist | Interviewed regarding contracture management |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation deficiencies |
| Dietary Aide 4 | Dietary Aide | Observed and interviewed regarding improper handling of food items |
| [NAME] 3 | Dietary Staff | Observed with soiled uniform and poor hand hygiene |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 9
Date: Sep 22, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00417481) regarding concerns about resident dignity, privacy, abuse reporting, personal care, foot care, range of motion management, IV therapy, staffing levels, and kitchen sanitation.
Complaint Details
Complaint IN00417481 triggered the inspection. The complaint involved concerns about resident dignity, privacy, abuse reporting, personal care, foot care, range of motion management, IV therapy, staffing levels, and kitchen sanitation. The complaint was substantiated with findings of deficiencies in these areas.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining assistance, privacy breaches, failure to report and investigate abuse allegations timely, inadequate response to personal care requests, lack of preventative foot care, insufficient contracture management, improper IV therapy maintenance and discontinuation, inadequate staffing levels, and poor kitchen sanitation practices.
Deficiencies (9)
F 0550: The facility failed to ensure dignity was maintained during dining assistance for 3 of 8 residents in the assisted dining room.
F 0583: The facility failed to ensure privacy for 3 of 24 residents during random observations, including leaving computer screens with personal information visible and staff entering rooms without knocking.
F 0609: The facility failed to timely report and investigate an allegation of abuse involving 2 residents.
F 0677: The facility failed to respond to a request for positioning and personal care for 1 of 7 residents reviewed for ADLs.
F 0687: The facility failed to develop and implement preventative foot care interventions for 1 resident with diabetes and history of toe amputation.
F 0688: The facility failed to ensure individualized contracture management interventions for 1 resident with range of motion decline.
F 0694: The facility failed to ensure intravenous therapy was maintained and discontinued properly for 1 of 3 residents reviewed.
F 0725: The facility failed to maintain adequate nursing and CNA staffing levels to meet resident needs on multiple days in September 2023.
F 0812: The facility failed to ensure kitchen sanitation and food safety practices, including unclean pans, debris on floors, improperly dated food items, and poor hand hygiene by staff.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 76
Facility census: 79
Nurse hours: 48
CNA hours: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 5 | Qualified Medication Aide | Named in dignity during dining assistance finding |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, abuse reporting, personal care, IV therapy, and contracture management |
| Administrator | Administrator | Interviewed regarding abuse reporting, staffing, and kitchen sanitation |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding privacy breach related to computer screen |
| Physical Therapy Assistant 8 | Physical Therapy Assistant | Named in privacy breach for entering room without knocking |
| LPN 15 | Licensed Practical Nurse | Interviewed regarding podiatry consult follow-up |
| Rehabilitation Director/Occupational Therapist | Rehabilitation Director/Occupational Therapist | Interviewed regarding contracture management |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen sanitation inspection |
| Dietary Aide 4 | Dietary Aide | Observed during kitchen sanitation inspection |
| [NAME] 3 | Dietary Staff | Observed during kitchen sanitation inspection with poor hand hygiene and soiled uniform |
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 9
Date: Sep 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00416862 and IN00417481.
Complaint Details
Complaint IN00416862 - No deficiencies related to the allegations are cited. Complaint IN00417481 - Deficiencies related to the allegations are cited at F550, F677, and F725.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, privacy violations, failure to report abuse allegations timely, inadequate assistance with activities of daily living, insufficient foot care, lack of individualized contracture management, improper IV therapy management, inadequate staffing levels, and kitchen sanitation issues.
Deficiencies (9)
Failed to ensure dignity was maintained during assisted dining for 3 residents.
Failed to ensure privacy for 3 residents and confidentiality of personal and medical records.
Failed to report and investigate allegations of abuse for 2 residents.
Failed to respond to a request with positioning and personal care for 1 resident.
Failed to develop and implement preventative foot care interventions for 1 resident with diabetes and foot complications.
Failed to ensure individualized contracture management interventions for 1 resident with decline in range of motion.
Failed to ensure intravenous therapy was maintained and discontinued properly for 1 resident.
Failed to maintain adequate staffing levels to provide assistance with repositioning and personal care for 2 residents.
Failed to ensure kitchen sanitation including cleanliness of pans, cabinetry, floors, proper food storage and labeling, and hand hygiene of staff.
Report Facts
Census: 79
Total Capacity: 79
Medicare Census: 6
Medicaid Census: 54
Other Payor Census: 19
Deficiency Counts: 9
Staffing Hours - Licensed Nurses: 48
Staffing Hours - CNAs: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named as Administrator signing report and interviewed regarding staffing and abuse reporting |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding IV placement and computer screen privacy |
| QMA 5 | Qualified Medication Aide | Observed assisting residents during dining and interviewed about staffing |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, privacy, abuse reporting, IV therapy, and contracture management |
| Physical Therapy Assistant 8 | Physical Therapy Assistant | Observed entering resident room without knocking |
| Cook 3 | Cook | Observed with poor hand hygiene and contaminated uniform during food preparation |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen sanitation inspection |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on September 22, 2023.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
An investigation of Complaint Number IN00415890 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) related to Life Safety Code compliance.
Complaint Details
Complaint IN00415890 was substantiated with a federal/state deficiency cited at K100 related to the allegation of unsafe PTAC units causing smoke and fire risk.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to maintain 50 of 50 Packaged Terminal Air Conditioners (PTACs) in a safe operational condition, which could cause overheating and fire. The PTAC units were found dirty and had not been cleaned for two to three years, posing a fire risk.
Deficiencies (1)
Failure to ensure 50 of 50 Packaged Terminal Air Conditioners (PTAC) were maintained in a safe operational condition to prevent fire due to motor overheating and debris buildup.
Report Facts
Facility capacity: 115
Census: 81
PTAC units inspected: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named during interview and exit conference regarding findings |
Inspection Report
Renewal
Deficiencies: 1
Date: Jun 7, 2023
Visit Reason
The inspection was conducted as an offsite Licensure Investigation Survey to review the facility's compliance with timely renewal of its license to operate as a health care facility.
Findings
The facility failed to timely renew its license before the expiration date of May 31, 2023, as the renewal application and payment were submitted on June 1, 2023, which was not at least 45 days prior to license expiration as required by state regulations.
Deficiencies (1)
Facility failed to ensure timely renewal of license to operate before expiration on May 31, 2023.
Report Facts
Days prior to license expiration required for renewal application: 45
Date license expired: May 31, 2023
Date renewal application submitted: Jun 1, 2023
Date systemic changes to prevent recurrence will be completed: Jun 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Smalley | Regulatory Compliance Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on the report. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409182.
Complaint Details
Investigation of Complaint IN00409182 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 71
Medicare Census: 3
Medicaid Census: 52
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395108.
Complaint Details
Complaint IN00395108 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 73
Census total residents: 73
Census Medicare residents: 10
Census Medicaid residents: 49
Census other payor residents: 14
Inspection Report
Re-Inspection
Census: 86
Capacity: 115
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 11/02/22.
Findings
At this PSR survey, Mason Health and Rehabilitation was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 115
Census: 86
Inspection Report
Re-Inspection
Census: 79
Capacity: 79
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 26, 2022.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 20
Inspection Report
Routine
Census: 86
Capacity: 115
Deficiencies: 8
Date: Nov 2, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification were conducted to assess compliance with federal and state regulations including emergency preparedness requirements and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing Plan. Additionally, the facility failed to ensure exit doors were accessible without special tools or keys, failed to provide staff access to the cooktop shutoff switch in the therapy gym, and failed to maintain proper mechanical ventilation in the oxygen storage room.
Deficiencies (8)
Failed to review and update the Emergency Preparedness Plan at least annually.
Failed to review and update the Emergency Preparedness Policies and Procedures at least annually.
Failed to review and update the Emergency Preparedness Communication Plan at least annually.
Failed to review and update the Emergency Preparedness Training and Testing Plan at least annually.
Failed to conduct annual emergency preparedness training for all staff.
Exit doors on 100, 300, and 400 halls were magnetically locked and required a code not posted at the exits, restricting egress.
Staff did not have access to the shutoff switch for the cooktop in the therapy gym.
Oxygen storage/transfer room ventilation fan motor was not working, failing to provide required mechanical ventilation.
Report Facts
Certified beds: 115
Census: 86
Deficiency count: 8
Residents potentially affected: 55
Residents potentially affected: 5
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named in relation to emergency preparedness findings and exit conference |
| Maintenance Director | Named in relation to emergency preparedness findings, exit door lock issues, cooktop shutoff, and oxygen room ventilation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392142.
Complaint Details
Complaint IN00392142 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 16
Medicaid residents: 45
Other payor residents: 19
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 9
Date: Sep 26, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 19 to 26, 2022.
Findings
The facility was found deficient in multiple areas including care planning, pressure ulcer prevention and treatment, urinary catheter care, respiratory care, dialysis communication, psychotropic medication monitoring, food safety, and infection control practices.
Deficiencies (9)
Failed to provide a comprehensive care plan for skin condition and oxygen use for 2 residents.
Failed to revise care plan timely for a resident on a weight loss regimen.
Failed to implement pressure relieving interventions to prevent an unstageable pressure wound for 1 resident.
Failed to provide dignity cover for urinary catheter drainage bag for 1 resident.
Failed to ensure respiratory equipment was dated, tracked, and changed properly; non-nursing staff improperly changed oxygen tubing for 4 residents.
Failed to complete post dialysis assessments and dialysis communication for 1 resident.
Failed to monitor for adverse side effects of psychotropic medications and complete AIMS assessments timely for 4 residents.
Failed to ensure food items were dated, sealed, labeled, and refrigerators clean in kitchen and pantries.
Failed to ensure proper infection control practices including PPE use during aerosol generating procedures, medication administration without touching medication with bare hands, and proper hand hygiene and glove use during wound care.
Report Facts
Survey dates: 6
Residents reviewed for care planning: 24
Residents reviewed for pressure ulcers: 3
Residents reviewed for respiratory care: 4
Residents reviewed for psychotropic medication monitoring: 5
Food items undated or unsealed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Entered resident room without proper PPE during aerosol generating procedure | |
| Qualified Medication Aide | Entered resident room without proper PPE during aerosol generating procedure | |
| Licensed Practical Nurse | Did not wash hands or change gloves properly during wound care | |
| Registered Nurse | Opened medication capsules with bare hands |
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