Chalet Rehabilitation And Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 1 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area and while serving the meal. (Cook 4) Finding includes: During a follow-up kitchen observation on 6/1/26 from 12:20 p.m. to 12:40 p.m., [NAME] 4 was observed working at the food preparation table located on the opposite side of the steam table that held the noon foods. [NAME] 4 was observed preparing the resident's food trays. [NAME] 4 was observed to have facial hair, approximately one-half inch in length, located above the upper lips and sideburns located in front of both ears. The facial hair above the lips and the sideburns were observed to not be covered. During an interview on 6/1/26 at 1:20 p.m., the Dietary Manager indicated staff hair, including facial hair, was to be kept covered while in the kitchen. On 6/1/26 at 1:46 p.m., the Dietary Manager provided an undated copy of the Personal Hygiene and Health Reporting policy and indicated it was the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for residents requiring Enhanced Barrier Precautions (EBP) for 1 of 5 residents reviewed for EBP. Gowns were not worn during direct resident care. (Resident 74, CNA 2, and CNA 3)Finding includes: On 6/1/26 at 10:10 a.m., a sign was observed on Resident 74's door indicating EBP (gown and gloves) were required for direct resident care. CNA 2 and CNA 3 were observed to be providing care to Resident 74. CNA 2 and CNA 3 were observed to be wearing only gloves. CNA 2 was observed cleansing Resident 74's groin area with a washcloth. At that time, CNA 3 had begun to don a gown. CNA 2 stopped providing direct care to Resident 74 donned a gown. During an interview at that time CNA 2 and CNA 3 indicated that a gown should have been donned prior to providing direct care to Resident 74. During an interview on 6/1/26 at 12:03 p.m., the Director of Nursing indicated that staff should wear EBP (gowns and gloves) when providing direct care to a resident that required EBP. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to protect a resident's rights to be free from verbal and mental abuse by the Administrator for 1 of 3 residents reviewed for abuse. (Administrator, Resident B)Finding includes:On 3/5/26 at 9:15 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition characterized by intense mood swings to extreme highs to severe lows) and PTSD (Post-traumatic stress disorder; a chronic mental health condition triggered by experiencing or witnessing terrifying events, causing symptoms such as nightmare, flashback, severe anxiety, and avoidance of triggers lasting over a month).The admission Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident B was cognitively intact.On 3/5/26 at 9:00 a.m., a facility reportable incident report was reviewed. The report was submitted to the Indiana Department of Health on 2/26/26 and a follow-up report was submitted on 2/27/26. The report indicated that on 2/19/26 the facility Administrator was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an incident of alleged staff to resident verbal and mental abuse was immediately reported to facility management, as indicated by facility policy, for 1 of 3 residents reviewed for reporting resident abuse. (Resident B, Administrator, Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, and Housekeeping Supervisor) Finding includes: On 3/5/26 at 9:00 a.m., facility reportable incident report was reviewed. The report was submitted to the Indiana Department of Health on 2/26/26, a follow-up report was submitted on 2/27/26, and a new update was submitted on 3/4/26. The report indicated that on 2/19/26 the facility Administrator was involved in verbal altercations against Resident B. The report indicated the Administrator's behaviors displayed against Resident B on 2/19/26 .violated the resident's rights and met the definition of abuse. Additionally, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staffing Coordinator, and Housekeeping Supervisor witnessed the Administrator's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's tube gastrostomy tube feeding was labelled for 1 of 2 residents reviewed for tube feeding. (Resident C) Findings include:On 2/13/26 at 12:21 p.m., Resident C was observed lying in bed. There was a tab-colored tube running from under Resident C's sheet up to a tube feeding pump at the side of the bed. The feeding pump was set to administer 60 milliliters (ml) of feeding per hour with a 40 ml water flush every hour. The feeding bag lacked a label that indicated the type of feeding, the rate of the feeding, the date and time the feeding was hung/administered, and the nurse's initials. At that time, LPN 2 indicated the feeding bag should have been labeled when the nurse hung it. The clinical record for Resident C was reviewed on 2/16/26 at 8:39 a.m. The diagnoses included, but were not limited to, traumatic brain injury, aphasia, dysphagia, and gastrotomy.A current physician's order, initiated 12/29/25, indicated Glucerna 1.5 at 60 ml per hour with 40 ml free water flush every hour.On 2/16/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for a resident with an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheters. (Resident C) Finding includes:On 1/6/26 at 11:20 a.m., observed Resident C to have an indwelling urinary catheter. At that time, Resident C indicated the staff had taken good care of his urinary catheter since it had been placed. The clinical record for Resident C was reviewed on 1/7/26 at 9:43 a.m. The diagnoses included, but were not limited to, obstructive uropathy and benign prostatic hyperplasia. A current physician's order, initiated on 8/7/25, indicated Resident C had an indwelling urinary catheter. The Quarterly Minimum Data Set (MDS) assessment, dated 11/15/25, indicated Resident C was moderately cognitively impaired and had an indwelling urinary catheter. The clinical record for Resident C lacked a comprehensive care plan for Resident C's indwelling urinary catheter. On 1/7/26 at 11:58 a.m., the Director of Nursing provided a copy of a facility policy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's with a peripherally inserted central line (PICC) (a small tube inserted into a vein in the upper arm that extends to the top of the heart used to administer intravenous fluid/medications) was dated and initialed for 1 of 2 residents reviewed for quality of intravenous (IV) care. (Resident D) Finding includes:On 1/6/26 at 10:28 a.m., observed Resident D to have an IV (a small catheter inserted into the vein) in the right upper arm. The IV dressing was not dated or initialed. At that time, Resident D indicated he had been receiving antibiotics through his PICC (peripherally inserted central catheter) line. The clinical record for Resident D was reviewed on 1/6/26 at 2:08 p.m. The diagnoses included, but were not limited to, acute hematogenous osteomyelitis, peripheral vascular disease, and diabetes. A current physician's order, initiated on 1/3/26, indicated to change PICC line dressing every seven days and as needed. An admission Minimum Data Set (MDS) assessment, dated 12/31/25, indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure documentation was complete for 2 of 3 residents reviewed. The Treatment Administration Record was incomplete. (Resident B, Resident C) Finding includes:1. On 1/6/26 at 11:20 a.m., observed Resident C to have an indwelling urinary catheter. At that time, Resident C indicated the staff had taken good care of his urinary catheter since it had been placed.The clinical record for Resident C was reviewed on 1/7/26 at 9:43 a.m. The diagnoses included, but were not limited to, obstructive uropathy and benign prostatic hyperplasia.A quarterly Minimum Data Set (MDS) assessment, dated 11/15/25, indicated Resident C was moderately cognitively impaired and had an indwelling urinary catheter.The physician's orders included, but were not limited to: - Ensure catheter bag is covered, maintain urinary drainage bag below the bladder, keep tubing and bag from touching the floor, and empty bag every shift, initiated on 8/7/25. - Provide catheter care every shift, initiated on 8/7/25. The December 2025 TAR, dated 12/1/25 at 12:00 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 18 residents observed for call light access. (Resident 52) Finding includes: On 3/30/25 at 8:36 a.m., Resident 52 was observed sitting up in his wheelchair in his room. The touch pad call light was observed to be wrapped around and clipped to the plug in cord at the foot of the bed between Resident 52's bed and the wall, out of reach of Resident 52. On 3/31/25 at 9:12 a.m., Resident 52 was observed in bed with the touch pad call light wrapped up and attached with a clip to the plug in cord at the foot of bed between the bed and the wall, out of reach of Resident 52. During an interview at that time, Resident 52 indicated he was unable to reach the call light. During an interview on 3/31/25 at 9:20 a.m., RN 2 indicated that the call light was not in within Resident 52's reach. During an interview on 3/31/25 at 9:23 a.m., the Director of Nursing (DON) indicated that Resident 52 could not reach his call light. During an observation on 4/2/25 at 9:02 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was correctly coded to reflect the hospice election status for 1 of 2 residents reviewed for hospice. (Resident 44) Finding includes: On 4/2/25 at 11:41 a.m., the clinical record of Resident 44 was reviewed. The diagnosis included, but was not limited to, acute kidney failure. A physician's order, dated 8/8/24, indicated Resident 44 was admitted hospice. An annual MDS assessment, dated 1/16/25, indicated Resident 44 was not receiving hospice services. During an interview on 4/2/25 at 10:57 a.m., the MDS Coordinator indicated Resident 44 had been receiving hospice services for a long time and indicated MDS assessment should have been updated. During an interview on 4/2/25 at 11:02 a.m., the Executive Director indicated the facility followed the RAI (Resident Assessment Instrument) manual regarding MDS assessment accuracy. On 4/2/25 at 12:01 p.m., the Executive Director provided a copy of the CMS RAI Version 3.0 Manual (Center for Medicare and Medicaid Services Resident Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a person-centered comprehensive care plan was accurately developed or implemented for residents' advanced directives, for 3 of 18 residents reviewed for advanced directive preferences. (Resident 23, Resident 29, Resident 281) Finding includes: 1. On [DATE] at 10:45 a.m., Resident 23's clinical record was reviewed. Resident 23's diagnoses included, but were not limited to, chronic obstructive pulmonary disorder and chronic pancreatitis. A physician's order, dated [DATE] and with no end date, indicated that Resident 23 had an advanced directive, or code status, of do not resuscitate or DNR (a medical order that instructs medical professionals not to attempt CPR if a patient's heart stops beating or breathing; this allows the patient to die naturally). A POST (Indiana Physician Orders for Scope of Treatment) form, prepared [DATE], indicated Resident 23 had selected do not attempt resuscitation/DNR. The form was signed by the resident. The care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advanced directive care plan was updated when the resident's code status preference was changed for 1 of 18 residents reviewed. (Resident 7) Finding includes: On [DATE] at 9:55 a.m., Resident 7's clinical record was reviewed. The diagnosis included, but was not limited to, chronic obstructive pulmonary disease. Current Physician orders, dated [DATE], included, but was not limited to, Code Status: CPR (cardiopulmonary resuscitation), start date [DATE] with no end date noted. The annual Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 7 was cognitively intact. Resident 7's care plan included, but was not limited to, .[Resident 7] has an established advanced directive of POST [Indiana Physician Orders for Scope of Treatment] form indicating DNR [do not attempt resuscitation/do not resuscitate] code status. The care plan was initiated on [DATE] and was considered current through [DATE]. On [DATE] at 12:55 p.m., the Executive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure staff reported an allegation of physical abuse immediately for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 1/3/24 at 1:27 p.m., the Administrator indicated on 12/30/23, an allegation was made that LPN 1 (Licensed Practical Nurse) witnessed LPN 2 and QMA 1 (Qualified Medication Aide) abruptly put Resident B in bed. Once Resident B was in bed, he sat up and LPN 2 kicked Resident B. It was alleged this took place a couple weeks ago but unfortunately it was not reported until 12/30/23. During an interview on 1/4/24 at 9:50 a.m., LPN 1 indicated approximately 2 to 3 weeks ago, on evening shift after 7:00 p.m., Resident B was on the floor, on his knees, at the foot of his bed. He had a small can in his hand that LPN 1 thought was shaving cream. LPN 1 asked LPN 2 and QMA 1 to help get Resident B off the floor and into his bed. LPN 1, LPN 2, and QMA 1 entered Resident B's room to get him up and LPN 2 indicated that Resident B's legs needed to be straightened first. After…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure food was stored in a sanitary manner for 1 of 1 kitchen observations. Food was not dated. Finding includes: During the initial tour of the kitchen on 9/13/23 from 9:01 a.m. until 9:40 a.m., the freezer and refrigerator were observed. Inside the freezer the following was observed: - A large clear plastic opened bag, undated, that contained 1 chicken breast that was observed to be covered with small ice crystals. - A large clear plastic opened bag, undated, that contained green vegetables that was observed to have small ice crystals throughout the bag. Inside the refrigerator the following was observed: - An opened, undated, glass 32 ounce container. The glass container was half full of great value pickles with a use by date of 6/18/23. - An opened, undated, clear plastic 30 ounce container. The plastic container was half full of mayonnaise. - An opened, undated, clear plastic gallon container. The gallon container was 3/4 full of unsweet tea with a best by date of 2/18/23. - An opened, undated, clear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.