Inspection Reports for
Chateau Rehabilitation and Healthcare Center

The complaint alleged Resident D was in poor shape, sent to the hospital, and staff ignored his condition assuming alcohol use. The investigation found failure to notify physicians of condition changes and refusal of treatment, lack of documentation of drug and alcohol screening, and failure to notify the nephrologist and dialysis team.

The facility failed to ensure Resident D's physicians were notified of a change in condition and refusal of treatment. Documentation was lacking regarding drug and alcohol screening, nursing assessments, and notifications to the nephrologist and dialysis team. Resident D refused dialysis and medications, was observed with altered consciousness, and was hospitalized with low oxygen saturation.

The facility was found to have multiple deficiencies including failure to administer insulin as ordered, failure to notify physicians of abnormal catheter assessments, inadequate trauma-informed care, improper medication storage and labeling, failure to serve mechanically altered diets as ordered, unsafe and unsanitary food storage and serving practices, and failure to maintain clean and intact ceiling tiles throughout the facility.

The visit was complaint-related, triggered by allegations of inadequate care leading to severe pressure injuries. The immediate jeopardy began on 2025-01-16 and was removed on 2025-04-25 after re-education of staff and correction of deficient practices.

The facility failed to properly assess, treat, and provide individualized interventions to prevent worsening of pressure injuries, resulting in Resident P developing an unstageable pressure injury to the coccyx and bilateral heel wounds. The resident was discharged with unreported wounds and later passed away due to complications. The facility was found to have inadequate documentation, delayed wound recognition, and failure to update care plans accordingly.

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.

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.

This citation is related to complaint IN00448990.

The facility failed to ensure ceiling return air ducts were free from debris for 3 of 10 vents observed, with gray, feathery debris noted on vents in multiple locations. The Administrator confirmed that vents should be free of debris, but the cleaning list did not include these vents.

Complaint IN00448990 was substantiated with federal/state deficiencies cited at F921. Complaint IN00450790 had no deficiencies related to the allegations.

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.

This citation refers to Complaint IN00442157. The complaint involved concerns about the reduction of antipsychotic medication without proper assessment or family notification, leading to resident agitation and injury.

The facility failed to properly assess and implement non-pharmacological interventions before reducing the dose of antipsychotic medication for Resident B, who subsequently became agitated and sustained a hip fracture. Documentation lacked evidence of family notification or agreement regarding medication changes, and the interdisciplinary team had not fully evaluated the impact of medication changes on the resident's behaviors and fall.

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.

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.

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.

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.

The facility was found deficient in ensuring proper fall interventions and communication for a resident at risk of falls, employing a licensed dietician as required by state regulations, cleaning shared glucometers between uses to prevent infection, and maintaining safe and intact flooring in resident areas.

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.

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.

The inspection relates to Complaint IN00426219 regarding notification and transfer information failures, Complaint IN00427321 regarding pressure ulcer care, and Complaint IN00427393 regarding dialysis medication administration.

The facility failed to notify the resident's Power of Attorney of a significant change in condition, failed to provide necessary clinical information to the hospital upon resident transfer, failed to follow physician orders for pressure ulcer care, and failed to ensure dialysis related medications were administered as ordered for multiple residents.

This deficiency relates to Complaint IN00422858.

The facility failed to provide appropriate treatment and care for Resident C's Addison's disease, including missed administration of prescribed Hydrocortisone medications for three days without notifying the physician or nurse practitioner. This led to the resident experiencing severe symptoms including unresponsiveness and hypoglycemia requiring emergency medical services and hospital transport.

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.

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.

This citation relates to Complaint IN00420057.

The facility failed to ensure that a stool sample was collected, processed, and followed up for one of three residents reviewed. Interviews and record reviews revealed that although the sample was collected, it was not processed within the recommended timeframe, and there was no documentation of follow-up or physician notification.

Complaint IN00419839 and IN00419926 had no deficiencies related to the allegations. Complaint IN00420057 was substantiated with federal/state deficiencies cited at F0773.

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 IN00418876 related to failure in wound care and dialysis services for Resident C, substantiated by findings of inadequate wound management, infection control issues, missed dialysis treatments due to equipment failure and transportation issues, and poor communication with the dialysis center.

The facility failed to provide adequate care and services for non-pressure related wounds and skin impairments for Resident C, resulting in infection control issues that led to the dialysis center refusing further treatment. Additionally, the facility failed to ensure ongoing communication with the dialysis center and had issues with transportation and equipment (hoyer lift) that caused missed dialysis treatments, contributing to the resident's hospitalization with sepsis.

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.

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 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.

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.

The complaint investigation focused on Resident Y who alleged neglect, refusal of care by staff, delayed responses to call lights, and inadequate management of her behavioral health needs. The investigation found substantiated issues including failure to follow physician orders for medication adjustments and lack of care plan addressing anxiety and substance use disorder.

The facility failed to implement an effective behavioral care plan for one resident, Resident Y, who exhibited multiple psychosocial and behavioral issues including refusal of care, anxiety, and substance use disorder. The resident experienced neglect, delayed responses to call lights, and inadequate management of medications and care plans related to her mental health and substance use.

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.

The facility was found deficient in multiple areas including failure to ensure resident privacy, failure to provide written notice of bed hold policy upon transfer, failure to obtain nurse permission before PRN medication administration by QMA, inadequate assessment and care implementation for residents, inconsistent respiratory care documentation, failure to provide appropriate dialysis assessments, inadequate social service interventions for transfer/discharge and PASRR, failure to attempt non-pharmacological interventions prior to psychotropic medication use, improper facial hair restraint in the kitchen, and failure to maintain an effective quality assurance process to prevent recurring deficiencies.

Complaint IN00412354 was investigated with no Federal/State deficiencies related to the allegations cited.

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.

This Federal tag relates to Complaints IN00409186 and IN00409348. The complaint investigation found that staff failed to assess and notify the physician about worsening wound conditions and did not document notifications or orders to send the resident to the hospital.

The facility failed to adequately assess and notify the physician of changes in a resident's worsening skin tear wound, which led to hospitalization for severe infection. Staff did not document notifications to the physician or hospital orders despite observed increased drainage, redness, and swelling.

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.

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.

This Federal tag relates to Complaint IN00408095 for toileting and incontinent care issues and Complaint IN00406632 for food temperature and dietary concerns.

The facility failed to resolve resident grievances in a timely manner, did not provide adequate assistance with toileting and incontinent care for a resident, and failed to serve food at a palatable temperature for several residents. Multiple residents and staff interviews, record reviews, and observations confirmed ongoing issues with call light response times, shower scheduling, housekeeping, dietary services, and assistance with activities of daily living.

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).

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.

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.

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.

Complaint IN00390451 was investigated and found unsubstantiated due to lack of evidence.

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.

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.

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.