Inspection Reports for Chateau Rehabilitation and Healthcare Center
6006 BRANDY CHASE COVE, IN, 46815
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a mixed pattern, with several citations related to resident care issues such as wound and pressure injury management, behavioral care planning, medication administration, and some environmental and safety concerns including Life Safety Code violations. Notable enforcement included an Immediate Jeopardy finding in early 2025 for failure to properly assess and treat a pressure injury, which was resolved after corrective actions. Most complaint investigations were unsubstantiated or found no deficiencies, with substantiated complaints generally resulting in citations but no fines or license actions listed in the available reports. The facility’s record shows some improvement in recent months with no deficiencies cited in the latest inspections following earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
371% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Jun 25, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00461700 and IN00462232.
Findings
No deficiencies related to the allegations in complaints IN00461700 and IN00462232 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461700 - No deficiencies related to the allegations are cited. Complaint IN00462232 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 88
Total Capacity: 88
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
May 28, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459713.
Findings
No deficiencies related to the allegations in Complaint IN00459713 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00459713 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 61
Other payor census: 18
Inspection Report
Re-Inspection
Census: 83
Capacity: 83
Deficiencies: 0
May 12, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00457597, IN00457901, and IN00457935 completed on April 25, 2025.
Findings
The facility 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 Investigation of Complaints. All three complaints were corrected.
Complaint Details
This visit was related to complaints IN00457597, IN00457901, and IN00457935. All complaints were corrected.
Report Facts
Census SNF/NF beds: 83
Census total residents: 83
Census Medicare residents: 5
Census Medicaid residents: 61
Census other payor residents: 7
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458304.
Findings
No deficiencies related to the allegations in Complaint IN00458304 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
Investigation of Complaint IN00458304 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 79
Census total residents: 79
Census Medicare residents: 5
Census Medicaid residents: 53
Census other payor residents: 21
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Apr 22, 2025
Visit Reason
The visit was conducted for the investigation of complaints IN00457597, IN00457901, and IN00457935 regarding alleged substandard quality of care resulting in pressure injuries.
Findings
The facility failed to ensure a resident (Resident P) received proper assessment, treatment, and individualized interventions to prevent worsening of a pressure injury to the coccyx, resulting in an unstageable pressure injury. The resident was discharged with untreated wounds and transferred to another facility where the wounds were identified as severe. The Immediate Jeopardy was removed after re-education of staff and corrective actions.
Complaint Details
The investigation was triggered by complaints IN00457597, IN00457901, and IN00457935. The complaints alleged substandard care related to pressure injuries. The facility was found to have Immediate Jeopardy beginning 1/16/25 due to failure to assess and treat pressure injuries. The Immediate Jeopardy was removed on 4/25/25 after corrective actions were implemented.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and treat a pressure injury to the coccyx resulting in an unstageable wound with dead tissue and infection. | SS=J |
Report Facts
Census: 84
Total Capacity: 84
Survey Dates: 4
Pressure Injury Measurements: 5
Pressure Injury Measurements: 4.8
Pressure Injury Measurements: 3.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 5 | Registered Nurse | Interviewed regarding care provided to Resident P and wound treatment |
| Administrator | Facility Administrator | Interviewed regarding wound care and orders for Resident P |
| Wound Nurse Practitioner | Wound Nurse Practitioner | Provided wound care consultation and treatment recommendations for Resident P |
| Certified Nurse Aide 2 | Certified Nurse Aide | Provided direct care to Resident P and reported observations of skin condition |
| Director of Nursing | Director of Nursing | Interviewed at receiving facility regarding wound assessment on admission |
| Unit Manager | Unit Manager | Interviewed at receiving facility regarding wound assessment on admission |
| Medical Nurse Practitioner | Medical Nurse Practitioner | Provided medical assessment and treatment orders at receiving facility |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Feb 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452466 and IN00453453.
Findings
No deficiencies related to the allegations in complaints IN00452466 and IN00453453 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00452466 and Complaint IN00453453 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 83
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 27
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2025
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00448990 completed on January 24, 2025.
Findings
Chateau Rehabilitation and Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00448990 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 1
Jan 24, 2025
Visit Reason
The visit was conducted for the investigation of complaints IN00448990 and IN00450790. Complaint IN00448990 resulted in federal/state deficiencies cited, while complaint IN00450790 had no deficiencies related to the allegations.
Findings
The facility failed to ensure ceiling return air ducts were free from debris for 7 of 10 vents observed, with gray, feathery debris noted on multiple ceiling air intake vents. The Administrator confirmed vents should be free of debris, and the facility's cleaning protocols did not include vent cleaning prior to the citation.
Complaint Details
Complaint IN00448990 was substantiated with federal/state deficiencies cited at F921. Complaint IN00450790 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure ceiling return air ducts were free from debris for 7 of 10 vents observed. | SS=D |
Report Facts
Census: 80
Total Capacity: 80
Medicare Residents: 4
Medicaid Residents: 49
Other Residents: 27
Vents Observed: 10
Vents Free from Debris: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Bates | HFA | Laboratory Director or Provider/Supplier Representative signing the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Dec 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448742.
Findings
No deficiencies related to the allegations in Complaint IN00448742 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00448742 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 49
Other payor census: 22
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446399 and IN00447016.
Findings
No deficiencies related to the allegations in complaints IN00446399 and IN00447016 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446399 - No deficiencies related to the allegations are cited. Complaint IN00447016 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 74
Medicare Census: 3
Medicaid Census: 46
Other Payor Census: 25
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Oct 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444524.
Findings
No deficiencies related to the allegations in Complaint IN00444524 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444524 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 8
Medicaid census: 47
Other payor census: 19
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 15, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00442157 completed on September 24, 2024.
Findings
Chateau 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 review of the complaint.
Complaint Details
Investigation of Complaint IN00442157 was completed and corrected.
Inspection Report
Re-Inspection
Census: 76
Capacity: 99
Deficiencies: 0
Oct 1, 2024
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 09/04/2024.
Findings
At this Post Survey Revisit, Chateau Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered with a fire alarm system including smoke detection in corridors and resident sleeping rooms.
Report Facts
Facility capacity: 99
Census: 76
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 1
Sep 24, 2024
Visit Reason
This visit was conducted as an investigation of Complaint IN00442157 regarding federal and state deficiencies related to allegations about quality of care at Chateau Rehabilitation and Healthcare Center.
Findings
The facility failed to ensure a comprehensive assessment, evaluation, and implementation of non-pharmacological approaches prior to decreasing a resident's antipsychotic medication. Specifically, Resident B experienced agitation and a fall resulting in a hip fracture after the dose reduction. Documentation lacked evidence of appropriate interventions, family notification, or agreement regarding medication changes.
Complaint Details
Complaint IN00442157 was substantiated with federal and state deficiencies cited related to the allegations. The investigation focused on quality of care concerning the management of antipsychotic medication for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a comprehensive assessment, evaluation, and non-pharmacological approaches prior to decreasing antipsychotic medication for Resident B. | SS=D |
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 9
Medicaid Census: 48
Other Payor Census: 20
Antipsychotic Medication Dose Reduction: 5
Antipsychotic Medication Dose Increase: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique Augustine | Executive Director | Signed the report and Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report letter |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 4, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure.
Findings
Chateau 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 review for the Recertification.
Inspection Report
Life Safety
Census: 74
Capacity: 99
Deficiencies: 6
Sep 4, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness communication requirements and multiple Life Safety Code deficiencies including unprotected smoke barrier penetrations, missing electrical receptacle cover, failure to conduct quarterly fire drills on all shifts, improper use of flexible cords as fixed wiring, and unsecured oxygen cylinders.
Severity Breakdown
SS=F: 2
SS=E: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness communication plan includes primary and alternate means for communicating with staff and emergency management agencies. | SS=F |
| Penetrations caused by a pipe through smoke compartment barriers were not protected to maintain smoke resistance. | SS=E |
| Electrical receptacle at C-Hall nurses' station was missing a cover plate. | SS=E |
| Failed to conduct quarterly fire drills for first shift in one quarter. | SS=F |
| Flexible cords were used as a substitute for fixed wiring in Human Resource office and above ceiling. | SS=E |
| One oxygen cylinder was not properly secured from falling. | SS=E |
Report Facts
Facility capacity: 99
Census: 74
Number of smoke compartments: 4
Number of oxygen cylinders observed: 6
Residents potentially affected by unsecured oxygen cylinder: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique Augustine | Executive Director | Named in relation to findings and exit conference. |
Inspection Report
Renewal
Census: 70
Capacity: 70
Deficiencies: 4
Aug 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 13 to 19, 2024.
Findings
The facility was found deficient in several areas including failure to ensure fall interventions were recorded and communicated for one resident, failure to employ a licensed dietitian in Indiana, failure to clean shared glucometers between uses, and failure to maintain safe and intact flooring panels in a resident's room.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure fall interventions were recorded and communicated for 1 of 6 residents reviewed (Resident 67). | SS=D |
| Failure to ensure the qualified/registered dietitian was licensed in Indiana, potentially affecting all 70 residents. | SS=F |
| Failure to ensure a shared glucometer was cleaned between uses for 3 of 12 residents reviewed (Residents 19, 29, and 30). | SS=D |
| Failure to ensure flooring panels were complete and intact for 1 of 24 residents reviewed (Resident 11). | SS=D |
Report Facts
Census: 70
Total Capacity: 70
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique L. Augustine | Health Facility Administrator | Signed the report and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the survey letter |
| LPN 9 | Named in infection control deficiency related to glucometer cleaning | |
| RD 6 | Registered Dietitian | Named in deficiency related to lack of Indiana dietitian license |
| Director of Nursing | Involved in fall prevention corrective actions and infection control education |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Aug 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438924.
Findings
No deficiencies related to the allegations in Complaint IN00438924 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
Complaint IN00438924 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 67
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Jul 16, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437244, IN00437590, and IN00437907.
Findings
No deficiencies related to the allegations in complaints IN00437244, IN00437590, and IN00437907 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00437244, IN00437590, and IN00437907 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Jun 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435181, IN00435762, and IN00436390.
Findings
No deficiencies related to the allegations in complaints IN00435181, IN00435762, and IN00436390 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00435181, IN00435762, and IN00436390 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 71
Total Capacity: 71
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 49
Census Payor Type Other: 17
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
May 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432799 and IN00433374.
Findings
No deficiencies related to the allegations in complaints IN00432799 and IN00433374 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of complaints IN00432799 and IN00433374 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 77
Medicare Census: 12
Medicaid Census: 49
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Apr 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429500, IN00430223, and IN00430862.
Findings
No deficiencies related to the allegations in complaints IN00429500, IN00430223, and IN00430862 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 investigation of these complaints.
Complaint Details
Complaints IN00429500, IN00430223, and IN00430862 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 78
Total Capacity: 78
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 20
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 4
Feb 7, 2024
Visit Reason
This visit was conducted as a complaint investigation for multiple complaints received by the Indiana State Department of Health regarding Chateau Rehabilitation and Healthcare Center.
Findings
The investigation found several deficiencies related to notification of changes, transfer and discharge requirements, pressure ulcer care, and dialysis medication administration. Some complaints were substantiated with federal and state deficiencies cited, while others had no deficiencies related to the allegations.
Complaint Details
The complaint investigation was triggered by multiple complaints (IN00425109, IN00426219, IN00427099, IN00427101, IN00427115, IN00427321, IN00427393, IN00427528, IN00427529, and IN00427620). Deficiencies were cited related to complaints IN00426219, IN00427321, and IN00427393. Other complaints had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify the Power of Attorney of a significant change in condition for 1 of 3 residents reviewed. | SS=D |
| Failed to provide information to the hospital upon transfer for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure physician orders were followed for pressure ulcer care for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure dialysis related medications were given as ordered for 3 of 3 residents reviewed. | SS=D |
Report Facts
Census: 78
Total Capacity: 78
Deficiencies cited: 4
Survey dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique L Augustine | Executive Director / Health Facility Administrator | Named as facility representative and signatory on report |
| Brenda Buroker | Director of Division Long Term Care | Recipient of complaint survey letter |
| RN 5 | Registered Nurse | Dialyze Direct nurse involved in communication about dialysis medication |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication availability and administration |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 7, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00426219, IN00427321, and IN00427393.
Findings
Chateau 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 Complaint Investigation.
Complaint Details
Investigation of Complaints IN00426219, IN00427321, and IN00427393 completed on February 7, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 4, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00422858 completed on December 13, 2023.
Findings
Chateau 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 IN00422858 completed on December 13, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 1
Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00421976, IN00422858, and IN00423759) at Chateau Rehabilitation and Healthcare Center.
Findings
The facility failed to provide adequate care and services for chronic conditions to one resident (Resident C), specifically related to Addison's disease and medication administration. Deficiencies were cited related to failure to administer prescribed Hydrocortisone medications and lack of appropriate care planning and staff knowledge regarding the resident's condition.
Complaint Details
Complaint IN00421976 and IN00423759 had no deficiencies related to the allegations. Complaint IN00422858 had federal/state deficiencies cited at F684 related to quality of care for Resident C.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide care and services for chronic conditions to 1 of 3 residents reviewed (Resident C) related to Addison's disease and medication administration. | SS=D |
Report Facts
Census: 77
Total Capacity: 77
Medicare residents: 4
Medicaid residents: 59
Other payor residents: 14
Missed Hydrocortisone doses: 4
Blood sugar readings: 33
Blood sugar readings: 24
Blood sugar readings: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique L. Augustine | Health Facility Administrator | Signed the report and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey letter |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication administration and knowledge of Resident C's Addison's disease |
| QMA 4 | Qualified Medication Aide | Interviewed regarding care of Resident C and knowledge of Addison's disease |
| Interim Administrator | Interviewed about medication administration policies | |
| Interim Director of Nursing | Director of Nursing | Interviewed about care plans and medication administration |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 1
Nov 3, 2023
Visit Reason
The visit was conducted to investigate complaints IN00419839, IN00419926, and IN00420057 at Chateau Rehabilitation and Healthcare Center.
Findings
No deficiencies were cited related to complaints IN00419839 and IN00419926. For complaint IN00420057, a deficiency was cited related to failure to ensure a stool sample was collected, processed, and followed up for one resident.
Complaint Details
Complaint IN00419839 and IN00419926 had no deficiencies related to the allegations. Complaint IN00420057 was substantiated with federal/state deficiencies cited at F0773.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a stool sample was collected, processed, and followed up for 1 of 3 residents reviewed (Resident C). | SS=D |
Report Facts
Census: 90
Total Capacity: 90
Medicare Census: 4
Medicaid Census: 67
Other Payor Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique Augustine | Health Facility Administrator | Signed Plan of Correction and correspondence related to the complaint survey |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 3, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00420057.
Findings
The facility 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
Complaint IN00420057 was investigated and the facility was found to be in compliance.
Inspection Report
Re-Inspection
Census: 89
Capacity: 99
Deficiencies: 0
Nov 3, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/12/23 was performed to verify compliance with fire 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 building was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 99
Census: 89
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00416441 completed on September 29, 2023.
Findings
Chateau 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
Complaint IN00416441 was investigated and found to be in compliance based on the paper review.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00418876 completed on October 4, 2023.
Findings
The facility 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
Complaint IN00418876 was investigated and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 2
Oct 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418876 regarding federal and state deficiencies related to allegations at the facility.
Findings
The facility failed to provide adequate care for non-pressure related wounds and skin impairments for one resident and failed to ensure ongoing communication with a dialysis facility for one resident receiving dialysis services. Issues included inadequate wound care, infection control concerns at the dialysis center, missed dialysis treatments due to equipment failure and transportation issues, and lack of coordination between the facility and dialysis center.
Complaint Details
Complaint IN00418876 was investigated. The complaint involved allegations of inadequate wound care and dialysis coordination for Resident C. The complaint was substantiated with federal/state deficiencies cited at F684 and F698.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide care and services for non-pressure related wound and skin impairments for 1 of 1 residents reviewed (Resident C). | SS=D |
| Failed to ensure ongoing communication with a dialysis facility for 1 of 2 residents receiving dialysis services (Resident C). | SS=D |
Report Facts
Census: 84
Total Capacity: 84
Dialysis treatments received: 2
Dialysis schedule: 3
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique L. Augustine | Health Facility Administrator | Signed the Plan of Correction letter |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the Plan of Correction letter |
| Director of Nursing | Interviewed regarding wound documentation and dialysis coordination | |
| Assistant Director of Nursing | Interviewed regarding mechanical hoyer lift issues affecting dialysis transport | |
| Clinical Manager | Dialysis Center | Interviewed regarding Resident C's dialysis treatments and infection control concerns |
| Clinical Support Nurse | Interviewed regarding facility policies on dialysis assessments and communication |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 1
Sep 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00416160, IN00416339, and IN00416441 at Chateau Rehabilitation and Healthcare Center.
Findings
The facility was found to have no deficiencies related to complaints IN00416160 and IN00416339. However, for complaint IN00416441, the facility failed to implement an effective behavioral care plan for one resident (Resident Y) with mental and psychosocial concerns, including failure to follow physician medication orders and address anxiety and substance use in the care plan.
Complaint Details
Complaint IN00416160 and IN00416339 had no deficiencies related to the allegations. Complaint IN00416441 was substantiated with federal/state deficiencies cited at F742 related to failure in behavioral care planning and medication management for Resident Y.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement an effective behavioral care plan for Resident Y with mental and psychosocial concerns, including anxiety and substance use disorder management. | SS=D |
Report Facts
Census: 86
Total Capacity: 86
Medicare Census: 6
Medicaid Census: 64
Other Payor Census: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy S. Vasil | Executive Director | Signed the report and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey letter |
Inspection Report
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 0
Sep 12, 2023
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-08-08.
Findings
Chateau Rehabilitation and Healthcare 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: 5
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 15
Inspection Report
Life Safety
Census: 80
Capacity: 99
Deficiencies: 9
Sep 12, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 09/12/2023 to assess compliance with federal and state regulations including 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain latching hardware on smoke barrier doors, impeded exit discharge doors, obstructed corridor means of egress, non-self-closing hazardous area doors, corridor doors not resisting smoke passage, exposed electrical wiring, and improper use of power strips and extension cords.
Severity Breakdown
SS=E: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 7 smoke barrier doors. | SS=E |
| Failed to maintain 2 of 12 exit discharge doors free of impediments to full instant use. | SS=E |
| Failed to ensure 1 of 12 corridor means of egress were continuously maintained free of obstructions. | SS=E |
| Failed to ensure corridor doors to 5 of 5 hazardous rooms were provided with self-closing devices. | SS=E |
| Failed to ensure 1 of 1 corridor door was provided with means suitable for keeping the door closed and resisting passage of smoke. | SS=E |
| Failed to ensure 2 electrical wirings were protected; exposed wiring at outside light and emergency light. | SS=E |
| Failed to ensure 1 of 1 power strips were not used as a substitute for fixed wiring to provide power to high current draw equipment. | SS=E |
| Failed to ensure 1 of 1 resident rooms did not use multi-plug adaptors as a substitute for fixed wiring. | SS=E |
| Failed to ensure power strip used in resident care vicinity met UL1363A or UL60601-1 standards. | SS=E |
Report Facts
Facility capacity: 99
Census: 80
Deficiency count: 9
Residents potentially affected: 40
Residents potentially affected: 30
Residents potentially affected: 20
Residents potentially affected: 10
Residents potentially affected: 2
Residents potentially affected: 5
Residents potentially affected: 5
Residents potentially affected: 2
Residents potentially affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Vasil | Executive Director | Signed report and referenced in plan of correction correspondence |
| Maintenance Director | Interviewed and involved in observations and corrective actions for multiple deficiencies |
Inspection Report
Annual Inspection
Census: 87
Capacity: 87
Deficiencies: 10
Aug 8, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00412354.
Findings
The facility was found deficient in multiple areas including privacy violations, failure to provide written notice of transfer, medication administration errors, inadequate care planning and assessment for dialysis and respiratory care, improper food safety practices, and deficiencies in quality assurance processes.
Complaint Details
Complaint IN00412354 was investigated with no Federal/State deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 8
SS=E: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure privacy related to medical treatments for 1 of 24 residents (Resident 144) due to labeling dialysis transport chairs with resident's name and time. | SS=D |
| Failed to provide written Notice of Bed Hold Policy before or upon transfer for 2 of 18 residents (Residents 34 and 20). | SS=D |
| Failed to ensure nurse's permission was obtained prior to administration of PRN medication by Qualified Medication Aide for 1 of 16 residents (Resident 143). | SS=D |
| Failed to ensure assessment and implementation of care according to individualized resident needs for 2 of 19 residents (Residents 48 and 144), including monitoring dialysis catheter site and pain management. | SS=D |
| Failed to ensure consistent respiratory care for 1 of 3 residents with respiratory therapy (Resident 25), including documentation of oxygen tubing changes and humidification. | SS=D |
| Failed to provide assessments before and after dialysis treatments for 2 of 3 residents reviewed (Residents 144 and 34). | SS=D |
| Failed to ensure appropriate social service interventions for Notice of Transfer or Discharge and PASRR for 3 of 4 residents (Residents 20, 81, and 34). | SS=D |
| Failed to ensure non-pharmacological interventions were attempted prior to obtaining orders for antipsychotic medication for 1 of 5 residents (Resident 21). | SS=D |
| Failed to ensure facial hair was properly restrained on staff in the kitchen, risking food contamination. | SS=E |
| Failed to ensure a process was in place to identify and correct quality deficiencies from reoccurring issues, including dialysis assessment documentation. | SS=F |
Report Facts
Census: 87
Total Capacity: 87
Survey Dates: 5
Deficiency Severity Counts: 8
Deficiency Severity Counts: 1
Deficiency Severity Counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Myers | Director of Nursing | Named in relation to medication administration and survey report |
| Cathy Vasil | Executive Director | Signed Plan of Correction and correspondence |
| Brenda Buroker | Director of Division Long Term Care | Recipient of survey report correspondence |
| Licensed Practical Nurse 3 | Interviewed regarding transfer policy and medication administration | |
| Licensed Practical Nurse 7 | Interviewed regarding resident behavior and medication | |
| Qualified Medication Aide 4 | Interviewed regarding medication administration | |
| Registered Nurse 10 | Interviewed regarding dialysis communication | |
| Social Services Director 5 | Interviewed regarding PASRR process | |
| Social Services Director 6 | Interviewed regarding PASRR process | |
| Regional Director of Operations for Dining Services | Interviewed regarding food safety and facial hair policy | |
| Administrator | Interviewed regarding QAPI and policies | |
| Director of Nursing | Interviewed regarding dialysis program and medication policies |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Jun 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410273.
Findings
No deficiencies related to the allegations in Complaint IN00410273 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
Investigation of Complaint IN00410273 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 84
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 19, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00406632 and IN00408095 completed on May 18, 2023.
Findings
Chateau 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 of the complaint investigations.
Complaint Details
The visit was related to the investigation of Complaints IN00406632 and IN00408095. The facility was found to be in compliance based on the paper review.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 19, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00409186 and IN00409348 completed on May 31, 2023.
Findings
Chateau 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 review of the investigation complaints.
Complaint Details
Investigation of Complaint IN00409186 and IN00409348; paper compliance review completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 1
May 30, 2023
Visit Reason
This visit was conducted as an investigation of complaints IN00409186 and IN00409348 regarding the facility's care practices.
Findings
The facility failed to properly assess and notify the physician of changes in a non-pressure related wound for one resident, resulting in worsening infection and hospitalization. The facility submitted a plan of correction and requested a desk review for compliance.
Complaint Details
The complaint investigation involved allegations related to wound care and failure to notify the physician of changes in the resident's wound condition. The complaints IN00409186 and IN00409348 were substantiated with deficiencies cited at F684.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to assess a non-pressure related wound and notify the physician of observed changes for 1 of 3 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 86
Total Capacity: 86
Antibiotic treatment duration: 3
Antibiotic treatment duration: 10
Wound size length: 10
Wound size width: 3.5
Wound size depth: 1.8
Deficiency citation count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Vasil | Executive Director | Signed the report and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey report |
| LPN 3 | Nurse involved in wound care and interview regarding wound assessment | |
| LPN 4 | Nurse interviewed about wound care and communication with physician | |
| LPN 5 | Nurse interviewed about wound assessment and physician notification |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 3
May 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406632 and IN00408095 at Chateau Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in timely resolution of resident grievances related to call light response, showers, housekeeping, and dietary services. Additionally, failure to provide adequate assistance with toileting and incontinent care for a dependent resident was noted. The facility also failed to provide food at palatable temperatures for several residents.
Complaint Details
The complaint investigation involved two complaints: IN00406632 and IN00408095. Deficiencies related to IN00406632 were cited at F804 (food temperature and quality issues). Deficiencies related to IN00408095 were cited at F677 (ADL care for dependent residents).
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure grievances were resolved in a timely manner for 3 of 3 months reviewed, including issues with call light response times, showers, housekeeping, and dietary services. | SS=D |
| Failure to provide assistance with toileting and incontinent care for 1 of 3 residents reviewed (Resident E). | SS=D |
| Failure to provide food at a palatable temperature for 4 of 6 residents interviewed. | SS=E |
Report Facts
Census: 87
Total Capacity: 87
Residents interviewed with food temperature concerns: 4
Months with unresolved grievances: 3
Residents reviewed for toileting assistance: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Vasil | Executive Director | Signed the report and Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey report |
| Resident Council President | Interviewed regarding unresolved grievances | |
| Activities Director | Conducts Resident Council meetings and reported follow-up issues | |
| Director of Nursing | Director of Nursing (DON) | Provided CNA care documentation for Resident E |
| Dietary Manager | Interviewed regarding food temperature and hot plate availability | |
| CNA 8 | Certified Nurse Aide | Interviewed about care provided to Resident E |
| CNA 9 | Certified Nurse Aide | Interviewed about ADL care documentation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
May 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00409770 and IN00409840.
Findings
No deficiencies related to the allegations in complaints IN00409770 and IN00409840 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00409770 - No deficiencies related to the allegations are cited. Complaint IN00409840 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 88
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 0
Apr 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405939.
Findings
No deficiencies related to the allegations in Complaint IN00405939 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 IN00405939 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 89
Total Capacity: 89
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Feb 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400304 and IN00400353.
Findings
Both complaints IN00400304 and IN00400353 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00400304 - Unsubstantiated due to lack of evidence. Complaint IN00400353 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 11
Inspection Report
Life Safety
Deficiencies: 0
Jan 19, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey following a Post Survey Review (PSR) that exited on 01/03/23 and a prior survey that exited on 11/10/22.
Findings
Chateau Rehabilitation & Health Care was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00395119, IN00395278, IN00396353, IN00396484, and IN00397060.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. Four of the complaints were unsubstantiated due to lack of evidence, and one complaint was substantiated but no deficiencies related to the allegations were cited.
Complaint Details
Complaint IN00395119 - Unsubstantiated due to lack of evidence. Complaint IN00395278 - Unsubstantiated due to lack of evidence. Complaint IN00396353 - Unsubstantiated due to lack of evidence. Complaint IN00396484 - Substantiated with no deficiencies cited. Complaint IN00397060 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF: 83
Total Capacity: 83
Medicare Census: 10
Medicaid Census: 62
Other Payor Census: 11
Inspection Report
Re-Inspection
Census: 83
Capacity: 99
Deficiencies: 4
Jan 3, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code deficiencies identified during the survey on 11/10/22.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to deficiencies related to self-closing attic smoke hatch doors, semiannual inspection of kitchen fire suppression systems, routine inspection and testing of fire and smoke doors, and proper use of power cords and extension cords in patient care areas. Plans of correction were submitted with completion dates of 01/18/2023.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 attic smoke hatch doors were self-closing and kept closed unless held open by a compliant release device. | SS=E |
| Failed to ensure 2 of 3 kitchen fire suppression systems were inspected semiannually as required. | SS=E |
| Failed to ensure 10 of 10 smoke barrier door assemblies and 3 of 3 fire door assemblies and 2 of 2 oxygen room fire doors were routinely inspected and tested annually per NFPA 80 requirements. | SS=F |
| Failed to ensure 4 of 4 flexible extension cords and power strips were installed properly, used safely, and met required UL ratings in patient care locations. | SS=E |
Report Facts
Facility capacity: 99
Census: 83
Attic smoke hatch doors: 3
Kitchen fire suppression systems: 2
Smoke barrier door assemblies: 10
Fire door assemblies: 3
Oxygen room fire doors: 2
Flexible extension cords and power strips: 4
Residents potentially affected by attic smoke hatch doors deficiency: 35
Residents potentially affected by kitchen fire suppression deficiency: 25
Residents potentially affected by power cords deficiency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding deficiencies related to attic smoke hatch doors, kitchen fire suppression system inspections, fire door inspections, and power cord usage |
Inspection Report
Routine
Census: 89
Capacity: 99
Deficiencies: 18
Nov 10, 2022
Visit Reason
Routine Life Safety Code and Emergency Preparedness survey conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had multiple deficiencies related to emergency preparedness documentation, life safety code violations including exit door impediments, fire safety equipment maintenance, electrical safety, fire drills, and oxygen storage.
Severity Breakdown
SS=C: 2
SS=E: 8
SS=F: 5
Deficiencies (18)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan did not include a system to preserve resident medical documentation during an emergency. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance as required by NFPA 110 and Life Safety Code. | SS=C |
| Exit discharge door by DON office required excessive force to open due to paint causing door to stick. | SS=E |
| Means of egress through exit door with special locking arrangements was not readily accessible by staff due to lack of knowledge of door code. | SS=E |
| Three attic smoke hatch doors were not self-closing due to disconnected springs. | SS=E |
| Two kitchen fire suppression systems were not inspected semiannually as required by NFPA 96. | SS=E |
| Fire alarm system lacked documentation of semiannual visual inspection. | SS=F |
| Six sprinkler heads in laundry were loaded with dirt and lint. | SS=E |
| Portable fire extinguisher in chapel was unsecured and sitting on the floor. | SS=E |
| One set of smoke barrier doors would not close due to a patient lift blocking the door. | SS=E |
| Four electrical panel was not enclosed exposing energized parts. | SS=E |
| Electrical receptacles in resident rooms were not tested annually as required. | SS=F |
| Diesel power generator testing and inspection documentation was incomplete or missing for multiple required tests. | SS=F |
| Extension cords and power strips were improperly used and not UL rated in patient care areas. | — |
| Four oxygen cylinders in storage room were not properly secured from falling. | SS=E |
| Oxygen transfilling room was overcrowded and lacked proper signage. | SS=E |
| Fire drills were not conducted on each shift for 4 of 4 quarters, with no third shift fire drill conducted in past 12 months. | SS=F |
| Smoke barrier door assemblies were not routinely inspected or repaired; door labels were painted over and door frame had holes. | SS=F |
Report Facts
Facility capacity: 99
Current census: 89
Number of sprinkler heads loaded: 6
Number of oxygen cylinders unsecured: 4
Number of missing weekly generator inspections: 17
Number of missing fire drills: 7
Number of resident rooms with untested receptacles: 82
Number of extension cords/power strips misused: 11
Inspection Report
Annual Inspection
Census: 86
Capacity: 86
Deficiencies: 11
Sep 29, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00390451 which was unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including failure to provide adaptive call lights, failure to offer participation in care plan meetings, inadequate discharge planning, improper wound care procedures, failure to maintain range of motion, improper respiratory care equipment maintenance, incomplete dialysis assessment documentation, failure to provide mental health services for trauma, inadequate monitoring of opioid medication side effects, improper medication labeling and storage, and unsafe environmental conditions in the dining area.
Complaint Details
Complaint IN00390451 was investigated and found unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 8
SS=E: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure adaptive call lights were provided for 1 of 5 residents reviewed (Resident 41). | SS=D |
| Failure to ensure residents or family were offered participation in care plan meetings for 5 of 9 residents reviewed. | SS=E |
| Failure to assist in appropriate discharge planning for 1 of 1 resident reviewed (Resident 18). | SS=D |
| Failure to ensure pressure ulcer care was provided to promote healing and prevent infection in 1 of 1 resident reviewed (Resident 30). | SS=D |
| Failure to ensure range of motion was maintained in 1 of 2 residents reviewed (Resident 41). | SS=D |
| Failure to ensure oxygen tubing and supplies were maintained for 1 of 1 resident reviewed (Resident 86). | SS=D |
| Failure to ensure pre and post dialysis assessment documentation was available for 1 of 4 residents reviewed (Resident 29). | SS=D |
| Failure to provide services for mental/psychosocial concerns for 1 of 1 resident reviewed (Resident 18). | SS=D |
| Failure to monitor for side effects of opioid medications for 4 of 6 residents reviewed (Residents 18, 29, 45, and 191). | SS=E |
| Failure to ensure residents' medications were properly labeled, dated, and not utilized after expiration for 6 of 31 residents reviewed (Residents 2, 3, 11, 30, 41, and 50). | SS=E |
| Failure to ensure a safe, functional, sanitary, and comfortable environment in the dining area, including unsecured tools and blocked fire exit affecting 22 residents. | SS=E |
Report Facts
Survey dates: 5
Census: 86
Total capacity: 86
Residents with Medicare: 6
Residents with Medicaid: 66
Residents with other payor: 14
Date of Compliance: Oct 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Named in adaptive call light deficiency and range of motion observation |
| LPN 10 | Licensed Practical Nurse | Named in wound care procedure deficiency |
| ADON | Assistant Director of Nursing | Named in wound care procedure deficiency and dialysis assessment discussion |
| LPN 11 | Licensed Practical Nurse | Named in respiratory care tubing maintenance deficiency |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding care plan meetings, discharge planning, opioid monitoring, dialysis, and mental health services |
| Administrator in Training | Administrator in Training | Named in interviews regarding care plan meetings, dialysis, and mental health services |
| Maintenance 6 | Maintenance Staff | Named in environmental safety deficiency |
| QMA 9 | Qualified Medication Aide | Named in medication labeling deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 29, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey.
Findings
Chateau 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 review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 1
Sep 15, 2022
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00389258, IN00389460, IN00389533, IN00389595) regarding the facility's care and safety practices.
Findings
The facility was found to have failed in providing adequate supervision and safe transfer practices for a resident requiring extensive assistance, resulting in a right femur compression fracture. One complaint was substantiated and cited with a federal/state deficiency at F689.
Complaint Details
Four complaints were investigated: IN00389258, IN00389460, IN00389533 were unsubstantiated due to lack of evidence. Complaint IN00389595 was substantiated with a related deficiency cited at F689.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to appropriately transfer a resident requiring extensive assistance, resulting in a right femur compression fracture. | SS=G |
Report Facts
Census Bed Type: 89
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in the finding for failing to provide a safe transfer for Resident B |
| CNA 3 | Certified Nurse Aide | Involved in transfer of Resident B and named in the investigation |
| LPN 4 | Licensed Practical Nurse | Assisted Resident B and provided statements during investigation |
| QMA 6 | Qualified Medication Assistant | Observed Resident B's condition and notified nursing staff |
| QMA 9 | Qualified Medication Assistant | Provided information on proper transfer techniques |
| Administrator | Provided statements and corrective action information related to the deficiency | |
| DON | Director of Nursing | Provided statements and involved in investigation and corrective actions |
| Emergency Room Charge Nurse 8 | Provided information on Resident B's hospital admission and injury |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Aug 24, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387756 and IN00388109.
Findings
Complaint IN00387757 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00388109 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00387757 - Substantiated with no deficiencies cited. Complaint IN00388109 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 93
Total Capacity: 93
Medicare Census: 4
Medicaid Census: 75
Other Payor Census: 14
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 0
Aug 10, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00386495 and IN00386560.
Findings
Complaint IN00386495 was unsubstantiated due to lack of evidence. Complaint IN00386560 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 IN00386495 was unsubstantiated due to lack of evidence. Complaint IN00386560 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 90
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 5, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00384688 completed on July 20, 2022.
Findings
Chateau 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00384688 completed with paper compliance found.
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