Inspection Reports for Chalet Rehabilitation and Healthcare Center
4851 TINCHER RD, IN, 46221
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found the facility in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards. Earlier inspections showed a pattern of deficiencies primarily related to Life Safety Code issues such as incomplete maintenance documentation for smoke alarms, fire door problems, and emergency preparedness, as well as care plan and documentation deficiencies involving resident accommodations and advanced directives. Complaint investigations were mostly unsubstantiated, with one substantiated complaint involving food storage practices and another related to failure to immediately report an allegation of physical abuse, though no enforcement actions or fines were listed in the available reports. The facility has addressed many prior Life Safety Code deficiencies through subsequent reinspections, indicating some improvement in safety compliance. Overall, the inspection history reflects ongoing attention to life safety and care documentation with a trend toward resolving earlier cited issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
82% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 72
Capacity: 88
Deficiencies: 0
May 28, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/25/25 was performed to verify compliance with life safety and licensure requirements.
Findings
The facility 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 is fully sprinklered except for two detached storage buildings used for storage.
Report Facts
Facility capacity: 88
Census: 72
Inspection Report
Annual Inspection
Deficiencies: 0
May 6, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on April 3, 2025.
Findings
Chalet Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 70
Capacity: 88
Deficiencies: 3
Apr 25, 2025
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) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to incomplete documentation of preventative maintenance for battery-operated smoke alarms, a hazardous area door lacking a self-closing device, and a cross corridor smoke door with a gap larger than allowed. These deficiencies could affect residents, staff, and visitors.
Severity Breakdown
SS=C: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Incomplete documentation for preventative maintenance of battery-operated smoke alarms in resident rooms. | SS=C |
| One hazardous area door (Activities Office) was not equipped with a self-closing device. | SS=E |
| One of seven cross corridor smoke doors had a gap larger than 1/8 inch, failing to restrict smoke movement as required. | SS=E |
Report Facts
Certified beds: 88
Census: 70
Hazardous area doors: 10
Cross corridor smoke doors: 7
Gap size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanequa Footman | Executive Director | Named in relation to review of findings at exit conference |
| Maintenance Director | Interviewed and involved in findings related to smoke alarm maintenance and door deficiencies | |
| Maintenance Assistant | Mentioned as not completing weekly smoke detector testing |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Apr 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457945.
Findings
No deficiencies related to the allegations in Complaint IN00457945 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457945 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 10
Medicaid census: 41
Other census: 17
Inspection Report
Renewal
Census: 76
Capacity: 76
Deficiencies: 4
Apr 3, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 30 to April 3, 2025.
Findings
The facility was found deficient in several areas including failure to ensure reasonable accommodation of call light access for one resident, inaccurate coding of hospice election status in Minimum Data Set (MDS) assessments for one resident, failure to develop or implement comprehensive care plans reflecting advanced directives for three residents, and failure to update an advanced directive care plan when a resident's code status changed.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure reasonable accommodation of needs for 1 of 18 residents observed for call light access (Resident 52). | SS=D |
| Failed to ensure Minimum Data Set (MDS) assessment was correctly coded to reflect hospice election status for 1 of 2 residents reviewed for hospice (Resident 44). | SS=D |
| Failed to ensure a person-centered comprehensive care plan was accurately developed or implemented for residents' advanced directives for 3 of 18 residents (Residents 23, 29, 281). | SS=D |
| Failed to ensure an advanced directive care plan was updated when the resident's code status preference was changed for 1 of 18 residents (Resident 7). | SS=D |
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 7
Medicaid Census: 40
Other Payor Census: 29
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tanequa Footman | Executive Director | Named in relation to facility oversight and plan of correction |
| RN 2 | Interviewed regarding call light accessibility for Resident 52 | |
| Director of Nursing | Director of Nursing | Interviewed regarding call light accessibility and care plan updates |
| MDS Coordinator | Interviewed regarding hospice status and care plan accuracy | |
| Executive Director | Executive Director | Provided policy documents and interviews regarding MDS and care plans |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Mar 3, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452388, IN00453708, IN00454580, and IN00454588 at Chalet Rehabilitation and Healthcare Center.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00452388, IN00453708, IN00454580, and IN00454588 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 33
Total Census: 78
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Jan 8, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449825.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00449825 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 81
Total Capacity: 81
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 33
Census Payor Type Other: 41
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445446 and IN00443732.
Findings
No deficiencies related to the allegations in complaints IN00445446 and IN00443732 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445446 and Complaint IN00443732 were investigated with no deficiencies cited related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 33
Other payor census: 33
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Sep 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441356 and IN00441806.
Findings
No deficiencies related to the allegations in complaints IN00441356 and IN00441806 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00441356 - No deficiencies related to the allegations are cited. Complaint IN00441806 - No deficiencies related to the allegations are cited.
Report Facts
Medicare census: 8
Medicaid census: 28
Other payor census: 37
Inspection Report
Re-Inspection
Census: 73
Capacity: 88
Deficiencies: 0
Sep 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/17/24 was performed to verify compliance with life safety and licensure requirements.
Findings
The facility 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 is fully sprinklered except for two detached storage buildings used for storage.
Report Facts
Facility capacity: 88
Census: 73
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Jul 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00437969 and IN00438976.
Findings
No deficiencies related to the allegations in Complaints IN00437969 and IN00438976 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00437969 and Complaint IN00438976 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 34
Inspection Report
Life Safety
Census: 68
Capacity: 88
Deficiencies: 4
Jul 17, 2024
Visit Reason
A Life Safety Code Recertification and Emergency Preparedness Survey was conducted for Chalet Rehabilitation and Healthcare Center on 07/17/2024 by the Indiana Department of Health.
Findings
The facility was found not in compliance with Life Safety Code requirements including incomplete documentation for preventative maintenance of smoke detectors in resident rooms, a kitchen range hood exhaust system not maintained in proper working order, and a therapy room not properly separated from the corridor by smoke-resistant partitions. Additionally, quarterly fire drill documentation was incomplete for one quarter on the third shift.
Severity Breakdown
SS=F: 2
SS=D: 1
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure documentation for preventative maintenance of smoke detectors installed in all resident sleeping rooms was complete. | SS=F |
| Failed to ensure 1 of 1 kitchen range hood exhaust systems was maintained in proper working order; fan was not operational. | SS=D |
| Failed to ensure 1 of 1 therapy rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building. | SS=E |
| Failed to document quarterly fire drills on the third shift for 1 of 4 quarters. | SS=F |
Report Facts
Certified beds: 88
Current census: 68
Fire drills missing documentation: 1
Kitchen range hood exhaust systems: 1
Therapy rooms: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Executive Director | Named in relation to findings and plan of correction. |
Inspection Report
Renewal
Census: 72
Capacity: 72
Deficiencies: 0
Jun 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over June 25-28, 2024.
Findings
Chalet Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 36
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 23, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421975 completed on January 4, 2024, which resulted in an unrelated deficiency cited.
Findings
Chalet Rehabilitation and Healthcare 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 unrelated deficiency cited during the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Jan 4, 2024
Visit Reason
This visit was conducted as a complaint investigation (IN00421975) triggered by allegations of abuse at Chalet Rehabilitation and Healthcare Center.
Findings
No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was cited for failure to immediately report an allegation of physical abuse involving one resident. The facility provided a plan of correction and requested a desk review.
Complaint Details
Complaint IN00421975 was investigated with no deficiencies related to the allegations cited. The complaint involved an incident where LPN 2 kicked Resident B, but the incident was not reported immediately as required. The facility failed to report the allegation immediately but took corrective actions including education and auditing.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff reported an allegation of physical abuse immediately for 1 of 3 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Deficiencies cited: 1
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Executive Director | Signed the Plan of Correction and correspondence related to the complaint investigation |
| LPN 1 | Witnessed the abuse incident and failed to report immediately due to fear of retaliation | |
| LPN 2 | Alleged to have kicked Resident B during care | |
| QMA 1 | Involved in the incident with Resident B | |
| DON | Director of Nursing | Provided facility policy on abuse and incident reporting |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Oct 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419922.
Findings
No deficiencies related to the allegations in Complaint IN00419922 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419922 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 31
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00412623 completed on September 13, 2023.
Findings
Chalet Rehabilitation and Healthcare 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00412623 completed on September 13, 2023; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 1
Sep 13, 2023
Visit Reason
This visit was conducted as an investigation of Complaint IN00412623 regarding alleged deficiencies at Chalet Rehabilitation and Healthcare Center.
Findings
The facility failed to ensure food was stored in a sanitary manner in the kitchen, with multiple opened food containers undated and some past their use-by dates, violating food safety requirements.
Complaint Details
Complaint IN00412623 was substantiated with federal/state deficiencies cited related to food procurement, storage, preparation, and serving sanitary practices.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food was not dated and stored improperly in the kitchen, including opened containers in the freezer and refrigerator with no dates and some past use-by dates. | SS=E |
Report Facts
Census: 77
Total Capacity: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Executive Director | Signed Plan of Correction and correspondence |
| Dietary Manager | Interviewed regarding food storage and dating practices | |
| Regional Nurse | Provided facility policy on Safe Food Handling |
Inspection Report
Re-Inspection
Census: 75
Capacity: 88
Deficiencies: 0
Sep 12, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/18/23 was performed to verify compliance with life safety code requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered except for two detached storage buildings used for storage.
Report Facts
Facility capacity: 88
Census: 75
Inspection Report
Life Safety
Census: 71
Capacity: 88
Deficiencies: 4
Jul 18, 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) and NFPA 101 standards.
Findings
The facility was found not in compliance with Emergency Preparedness and Life Safety Code requirements, including failure to conduct monthly and annual testing of emergency lighting, incomplete documentation of sprinkler system inspections, improper mounting height of a portable fire extinguisher, and lack of annual inspection and testing of fire door assemblies.
Severity Breakdown
SS=C: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 2 battery backup emergency lights were tested monthly and annually for 90 minutes, and written records of inspections and tests were not provided. | SS=C |
| Failed to document sprinkler system inspections in accordance with NFPA 25, including missing weekly gauge inspections and monthly control valve inspections. | SS=E |
| Failed to ensure 1 of 22 portable fire extinguishers was installed with the top not exceeding five feet above the floor; one extinguisher was mounted at five feet six inches. | SS=E |
| Failed to ensure annual inspection and testing of 5 of 5 fire door assemblies in accordance with NFPA 80; no annual inspection records were available and the inspection document was blank. | SS=E |
Report Facts
Certified beds: 88
Current census: 71
Battery backup lights: 2
Portable fire extinguishers: 22
Fire door assemblies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Administrator / Executive Director | Named in letter and exit conference related to survey findings and plan of correction |
| Maintenance Director | Interviewed regarding emergency lighting testing, sprinkler system inspections, fire extinguisher mounting, and fire door inspections |
Inspection Report
Renewal
Census: 77
Capacity: 77
Deficiencies: 5
Jun 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 26 to June 30, 2023.
Findings
The facility was found deficient in several areas including failure to provide reasonable accommodations for residents, incomplete comprehensive care plans for medication monitoring, inaccurate posted nurse staffing information, failure to obtain laboratory orders for some residents, and failure to maintain a clean and sanitary environment in certain resident rooms and common areas.
Severity Breakdown
SS=D: 3
SS=C: 1
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide reasonable accommodation of needs for 1 of 24 residents reviewed; call light was out of reach (Resident 25). | SS=D |
| Failed to develop and implement a comprehensive care plan for monitoring side effects of psychotropic and antipsychotic medications for 1 of 5 residents reviewed (Resident 71). | SS=D |
| Failed to ensure daily posted nurse staffing reflected actual hours worked by staff for 5 of 5 days during the survey. | SS=C |
| Failed to obtain orders for laboratory services for 3 of 3 residents reviewed (Residents 28, 29, and 71). | SS=D |
| Failed to provide a clean, homelike environment for 4 of 24 rooms observed; liquid on floor and dirty commodes (Resident 24, Resident 182, Rooms 9, 10, 21). | SS=E |
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 7
Medicaid Census: 44
Other Payor Census: 26
Deficiency Count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Executive Director | Signed Plan of Correction and mentioned in report correspondence |
| Brenda Buroker | Director of Division Long Term Care | Recipient of report correspondence |
| Housekeeper 2 | Observed cleaning and interviewed regarding floor liquid and commode cleanliness | |
| Housekeeper 3 | Interviewed regarding commode cleanliness | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding call light policy, nurse staffing, and laboratory orders |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding medication monitoring and laboratory orders |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding Resident 25's call light use |
| Maintenance Director | Interviewed regarding commode repairs and work orders | |
| Housekeeping Supervisor | Interviewed regarding cleaning and commode caulking issues |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 30, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on June 30, 2023.
Findings
Chalet Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 24, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00405625 completed on April 17, 2023.
Findings
Chalet Rehabilitation and Healthcare 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00405625 completed on April 17, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 2
Apr 14, 2023
Visit Reason
The visit was conducted as an investigation of complaints IN00405625 and IN00405723 at Chalet Rehabilitation and Healthcare Center on April 14 and 17, 2023.
Findings
The facility was found deficient for failing to obtain physician orders for immediate care for one resident, and for failing to ensure routine medications were delivered timely for the same resident. Complaint IN00405625 deficiencies were cited; no deficiencies were found related to complaint IN00405723.
Complaint Details
Complaint IN00405625 was substantiated with federal/state deficiencies cited at F635 and F755. Complaint IN00405723 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure physician orders for immediate care were obtained following a new admission for 1 of 3 residents reviewed; specifically, orders for tracheostomy care were not obtained. | SS=D |
| Failed to ensure routine medications were delivered timely for 1 of 3 residents reviewed for new admissions. | SS=D |
Report Facts
Census: 70
Total Capacity: 70
Medicare Census: 5
Medicaid Census: 39
Other Payor Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Executive Director | Signed the Plan of Correction letter |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the Plan of Correction letter |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding Resident B's tracheostomy care orders and medication delivery |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident B's admission and orders |
| Regional Nurse | Interviewed and provided facility policies related to tracheostomy care and medication delivery |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 12, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00403489 completed on March 10, 2023.
Findings
Chalet Rehabilitation and Healthcare 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00403489 completed on March 10, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404670.
Findings
No deficiencies related to the allegations in Complaint IN00404670 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00404670 found no deficiencies related to the allegations.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 12
Medicaid Census: 40
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Mar 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00401942, IN00403489, and IN00403544, including a COVID-19 Focused Infection Control Survey.
Findings
Federal/State deficiencies related to complaint IN00403489 were cited at F580 for failure to notify the physician when a resident left the facility against medical advice. No deficiencies were cited related to complaints IN00401942 and IN00403544.
Complaint Details
Complaint IN00403489 was substantiated with deficiencies cited. Complaints IN00401942 and IN00403544 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to notify the physician when Resident B left the facility against medical advice. | SS=D |
Report Facts
Census: 73
Total Capacity: 73
Medicare Residents: 17
Medicaid Residents: 39
Other Payor Residents: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hughes | Administrator | Signed the report |
| Assistant Director of Nursing | Interviewed regarding Resident B leaving AMA, but no full name provided | |
| Director of Nursing | Provided facility policy on physician notification |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00394798 and IN00393596.
Findings
Complaint IN00394798 was unsubstantiated due to lack of evidence. Complaint IN00393596 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394798 was unsubstantiated due to lack of evidence. Complaint IN00393596 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 64
Total Capacity: 64
Medicare Census: 1
Medicaid Census: 37
Other Payor Census: 26
Inspection Report
Follow-Up
Census: 62
Capacity: 88
Deficiencies: 0
Nov 2, 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 09/06/22.
Findings
At this PSR, Chalet Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered except for two detached storage buildings which were not sprinklered.
Inspection Report
Life Safety
Census: 71
Capacity: 88
Deficiencies: 19
Sep 6, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including means of egress obstructions, exit door locking issues, illumination deficiencies, sprinkler system maintenance, fire alarm system out of service policy, and emergency preparedness plan deficiencies.
Deficiencies (19)
| Description |
|---|
| Wheelchair scale stored in corridor obstructing means of egress. |
| Exit doors had keypad codes posted on maglocks but alarms malfunctioned and codes were not easily identified. |
| One exit sidewalk lacked exterior lighting. |
| Exit signs had directional arrows popped out incorrectly and one courtyard door lacked NO EXIT signage. |
| Cooktops in therapy and activity rooms were not deactivated when not in use. |
| Kitchen staff not instructed on proper use of UL 300 hood fire suppression system. |
| Incomplete fire watch policy for fire alarm system out of service. |
| Sprinkler heads covered with corrosion in kitchen and janitor closet. |
| Sprinkler escutcheons hanging down from ceiling leaving gaps to attic space. |
| Fuel-fired boiler inspection certificate expired since 01/23/2020. |
| Two GFCI receptacles in West Hall Soiled Utility Room were not properly wired and did not provide GFCI protection. |
| Incomplete fire safety plan lacking staff response to battery powered smoke alarms in resident rooms. |
| Cigarette butts improperly disposed in resident and staff smoking areas. |
| Oxygen transfilling room fire door annual inspection incomplete, missing key inspection elements. |
| Oxygen cylinders not properly secured in resident room. |
| Oxygen transfilling room mechanical ventilation fan heavily covered with dirt/dust. |
| Oxygen transfilling room door held open during oxygen transfer. |
| Incomplete annual inspection and testing documentation for oxygen room fire door assembly. |
| Two inch holes in smoke barrier wall not properly fire stopped. |
Report Facts
Certified beds: 88
Current census: 71
Deficiency count: 19
Sprinkler heads with corrosion: 12
Cigarette butts: 100
Cigarette butts: 25
Cigarette butts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed and acknowledged multiple deficiencies including fire watch policy, sprinkler corrosion, oxygen transfilling room issues, and fire door inspection. | |
| Director of Nursing | Present during observations and exit conference, acknowledged findings. | |
| Kitchen Staff #1 | Cook | Interviewed regarding UL 300 hood fire suppression system use. |
| Qualified Medical Assistant | Observed transfilling oxygen with door held open, acknowledged training but forgot to close door. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 29, 2022
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on July 25, 2022.
Findings
Chalet Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
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