Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chalet Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with bipolar disorder and PTSD, who was cognitively intact, was subjected to verbal and mental abuse by the facility Administrator during escalating altercations related to unpaid billing. While staff packed the resident’s belongings, the Administrator mocked the resident, referred to the resident as “handicapped” and an “unpaid customer,” insisted the resident could not remain, and ordered the resident to leave the room and building, responding “not my problem” when asked where the resident should go. Video clips recorded by the resident captured the Administrator’s disrespectful, mocking, and intimidating tone, which facility leadership confirmed met the definition of verbal and mental abuse and violated the facility’s abuse prevention policy.
Staff failed to immediately report an incident of alleged verbal and mental abuse by the Administrator toward a resident, despite multiple witnesses. The Administrator spoke to the resident in a mocking, degrading, and intimidating tone, including dismissive remarks about the resident’s concerns, while the DON, ADON, Staffing Coordinator, and Housekeeping Supervisor were in and out of the room and observed the interaction. Although facility policy required all staff who witness mistreatment or verbal abuse to report it immediately to administration or the compliance hotline, these staff did not intervene or report the allegation; the abuse was later reported by the resident to the Ombudsman, who then informed the CNO.
A resident with a history of cerebral infarct, left-sided hemiplegia, weakness, limited mobility, and impaired balance had a care plan requiring a two-person assist for bed mobility, but only one CNA provided care. While the CNA stood on one side of the bed and rolled the resident to the opposite side to adjust bedding, the resident rolled off the bed and fell to the floor, later being found to have sustained a proximal left tibia and fibula fracture. The resident was cognitively intact, and both the CNA and an LPN reported they were unaware of the two-person assist requirement, despite a facility policy stating that person-centered fall-prevention interventions would be implemented.
A resident with a history of traumatic brain injury, aphasia, dysphagia, and a gastrostomy was observed receiving continuous tube feeding through a pump set to deliver 60 ml/hr with 40 ml water flushes every hour, but the feeding bag in use was not labeled with the formula type, rate, date and time hung, or nurse initials. An LPN confirmed the bag should have been labeled when it was hung. Review of the clinical record showed a physician order for Glucerna 1.5 at 60 ml/hr with 40 ml free water flush every hour, and the facility’s enteral tube feeding policy required labeling and verification against the physician’s order, which did not occur in this instance.
A resident with obstructive uropathy, benign prostatic hyperplasia, and an indwelling urinary catheter did not have a comprehensive care plan addressing the catheter, despite having a physician’s order in place and a Quarterly MDS documenting moderate cognitive impairment and catheter use. Observation confirmed the presence of the catheter, and the resident reported staff had taken good care of it. Review of the facility’s Comprehensive Care Plans policy, provided by the DON, showed that a person-centered care plan was required within a specified timeframe after MDS completion, but the resident’s clinical record lacked such a catheter-specific care plan.
A resident with a PICC line receiving IV antibiotics was observed on multiple days with a right upper arm PICC dressing that was not dated or initialed, despite an order and facility policy requiring weekly dressing changes and documentation. The resident, who was cognitively intact, reported the dressing had not been changed for at least a week, while the TAR only showed a dressing placement/change on a single earlier date, with no date or initials on the dressing itself to confirm compliance.
Surveyors found that the facility failed to ensure complete documentation on TARs for two residents receiving catheter care, skin care, and complex wound treatments. One resident with an indwelling catheter had multiple shifts where required catheter care and catheter management orders were not documented. Another resident with multiple comorbidities and extensive wound and skin orders, including zinc oxide application, neurogenic bladder monitoring, wound cleansing, Medihoney, collagen, hydrocolloid dressings, and wound vac care, had numerous missed entries on the TAR across various shifts and scheduled treatment days. The DON acknowledged that TAR documentation should have been completed, and facility policy requires that all services provided be documented in the medical record.
A resident with severe protein calorie malnutrition and a heart valve replacement was repeatedly observed without access to a call light, as it was either out of reach or on the floor. The resident confirmed inability to reach the call light, and both RN and DON acknowledged the issue. Facility policy required call lights to be accessible, but this was not followed.
A resident with acute kidney failure who had been admitted to hospice was not correctly identified as receiving hospice services on the annual MDS assessment. The MDS Coordinator acknowledged the oversight, and facility leadership confirmed that the assessment should have been updated to reflect the resident's hospice status.
Three residents with documented advanced directives, including DNR and full code status, did not have their preferences reflected in their care plans. Despite having signed POST forms and physician orders specifying their choices, the care plans lacked this critical information, contrary to facility policy and staff acknowledgment.
A resident's care plan was not updated to reflect a change in code status from DNR to full code, despite documentation and confirmation of the new preference. The DON acknowledged the care plan should have been revised, and facility policy requires ongoing updates to care plans to reflect changes in resident status.
Administrator’s Verbal and Mental Abuse of a Resident Over Billing Dispute
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by the Administrator. Resident B, who had diagnoses including bipolar disorder and PTSD and was documented as cognitively intact on the admission MDS, reported that the Administrator engaged in escalating verbal altercations in the resident’s room while directing staff to pack the resident’s belongings. According to interviews with the Regional Director of Operations (RDO) and Chief Nursing Officer (CNO), video clips recorded on the resident’s phone showed the Administrator speaking in disrespectful, mocking, and intimidating tones, with multiple opportunities to deescalate or walk away that were not taken. A written “Video Evidence Summary” of the recordings documented that the Administrator mocked the resident by pretending to record them, referred to the resident as an “unpaid customer,” and repeatedly stated that the resident could not remain in the facility because their bill was unpaid. The Administrator also referred to the resident as “handicapped,” told the resident they needed to “exit immediately,” and, when the resident asked where they should go, responded “not my problem” and “leave my building,” insisting the resident leave the room before determining next steps. The RDO, CNO, and Regional Nursing Consultant all stated that the Administrator’s statements and tone met the facility’s definition of verbal and mental abuse and violated the facility’s Abuse Prevention and Prohibition policy, which requires that all residents be free from verbal and mental abuse.
Failure to Report Administrator’s Verbal and Mental Abuse of a Resident
Penalty
Summary
Facility staff failed to immediately report an incident of alleged staff-to-resident verbal and mental abuse to facility management or the facility’s compliance hotline, as required by facility policy. On 2/19/26, the Administrator was in Resident B’s room and, according to Resident B’s later report and a video evidence summary, spoke to the resident in a mocking, undignified, degrading, and intimidating tone, including responding “Not my problem” when the resident asked where she should go. The Administrator’s behavior was determined by the facility’s investigation to have violated the resident’s rights and to meet the definition of abuse. Multiple staff members, including the DON, ADON, Staffing Coordinator, and Housekeeping Supervisor, were present in and out of the room and witnessed the Administrator’s verbal and mental abuse toward Resident B. Despite witnessing the incident, the DON, ADON, Staffing Coordinator, and Housekeeping Supervisor did not intervene and did not report the alleged abuse to facility management or to the facility’s compliance hotline, as required by the facility’s Abuse and Incident Reporting Policy. That policy states that all alleged violations involving mistreatment and verbal abuse, which may be considered a type of mental abuse, must be reported immediately to the Administrator or other officials, and that if staff are aware of or witness any abuse, it must be reported. The abuse allegation was ultimately reported by Resident B to the local Ombudsman on 2/27/26, who then notified the CNO. The CNO confirmed through interview with Resident B that the Administrator had spoken in a mocking, undignified, and intimidating tone and that multiple staff had witnessed the incident but had not reported it.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to implement a resident’s person-centered fall prevention care plan interventions, specifically the requirement for two staff to assist with bed mobility. The resident had diagnoses including cerebral infarct and hemiplegia affecting the left nondominant side, and a care plan dated 10/1/25 identified a self-care deficit related to weakness, limited mobility, and impaired balance, with an intervention specifying two staff assist for bed mobility. A Quarterly MDS assessment indicated the resident was cognitively intact. Despite these documented needs, only one CNA provided care during the incident. According to interviews and progress notes, the CNA stood on the left side of the resident’s bed and rolled the resident onto her right side to provide care and adjust the sheet underneath. While the resident was lying on her right side, she rolled off the right side of the bed and fell to the floor. Progress notes documented that this was a witnessed fall from bed during care, after which the resident complained of left leg pain. An X-ray later showed a fracture involving the proximal left tibia and fibula with no displacement, and the resident was sent to the hospital. Both the CNA and the LPN who responded to the fall reported they were not aware that the resident required two staff for bed mobility, despite the facility’s fall management policy indicating that person-centered fall-related interventions to address fall prevention would be implemented.
Unlabeled Enteral Feeding Bag for Resident on G-Tube
Penalty
Summary
Surveyors found that a resident receiving continuous enteral nutrition via a gastrostomy tube had an unlabeled feeding bag in use. Observation showed the resident lying in bed with a tube connected to a feeding pump set to deliver 60 ml of formula per hour with a 40 ml water flush every hour, but the feeding bag did not display the type of formula, the feeding rate, the date and time it was hung, or the nurse’s initials. The LPN present acknowledged that the bag should have been labeled when it was hung. Record review showed the resident had diagnoses including traumatic brain injury, aphasia, dysphagia, and gastrostomy, with a physician’s order for Glucerna 1.5 at 60 ml per hour with 40 ml free water flush every hour. The facility’s enteral tube feeding policy required staff to document their initials, the date and time the formula was hung/administered, and to initial that the label was checked against the physician’s order, which was not done in this case. This failure to label the tube feeding bag according to facility policy for one resident receiving gastrostomy tube feeding constituted the cited deficiency.
Failure to Develop Comprehensive Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. During observation, the resident was noted to have an indwelling urinary catheter and reported that staff had taken good care of it since placement. Record review showed the resident had diagnoses including obstructive uropathy and benign prostatic hyperplasia, and a physician’s order for an indwelling urinary catheter initiated several months earlier. A Quarterly MDS assessment documented that the resident was moderately cognitively impaired and had an indwelling urinary catheter. Despite these findings and the facility’s policy requiring a person-centered comprehensive care plan to be developed within seven days of completion of the required MDS and no later than 21 days after admission, the clinical record lacked a comprehensive care plan addressing the resident’s indwelling urinary catheter. The Director of Nursing provided the current policy titled Comprehensive Care Plans, which outlined the required timeframe for developing such plans, but the resident’s record still did not contain a comprehensive care plan specific to the urinary catheter, leading to the cited deficiency.
Failure to Date and Initial PICC Line Dressing
Penalty
Summary
The facility failed to ensure safe and appropriate administration of IV therapy by not dating and initialing the dressing of a resident’s peripherally inserted central catheter (PICC) line as required. Surveyors observed the resident on two consecutive days with an IV/PICC dressing on the right upper arm that lacked a date and staff initials, despite a physician’s order initiated on 1/3/26 directing that the PICC dressing be changed every seven days and as needed. The resident, who was cognitively intact and receiving IV antibiotics through the PICC line, reported that he did not believe the dressing had been changed in over a week. The Treatment Administration Record indicated a PICC dressing placement/change on 1/3/26, but there was no way to verify ongoing compliance with the weekly change requirement from the dressing itself because it was not dated or initialed, contrary to the facility’s own policy for PICC/Midline/CVAD dressing changes.
Incomplete Treatment Administration Records for Ordered Catheter and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate Treatment Administration Records (TARs) for ordered treatments and care. For one resident with obstructive uropathy and benign prostatic hyperplasia who had an indwelling urinary catheter, the physician’s orders required that the catheter bag be kept covered, maintained below bladder level, kept off the floor, and emptied every shift, as well as catheter care every shift. Review of the TAR for December showed multiple shifts where documentation for these catheter-related treatments was left blank, including specific evening and night shifts, despite the resident having an ongoing catheter and reporting that staff had taken good care of it. For another resident with heart failure, diabetes, cellulitis of the right lower leg, and an above-knee amputation, the physician had ordered multiple skin, wound, and catheter-related treatments, many of them scheduled every shift or on specific days of the week (Mondays, Wednesdays, and Fridays). These orders included application of zinc oxide ointment to the coccyx, catheter care every shift, monitoring for neurogenic bladder symptoms every shift, cleansing and dressing of lower back skin tears, and various wound care treatments to the left thigh, hip, ischium, coccyx, and left lateral foot, including use of Medihoney, collagen, hydrocolloid, and wound vac dressings. The November TAR showed numerous blanks where these treatments and monitoring were to be documented on specified day, evening, and night shifts. During an interview, the DON stated that the documentation on the TARs should have been completed. The facility’s undated “Charting and Documentation” policy, identified by the DON as current, states that all services provided to residents shall be documented in the resident’s medical record. The survey findings concluded that, for two of three residents reviewed, the facility failed to ensure that documentation of ordered treatments and services was completed on the TARs, resulting in incomplete medical records in violation of the facility’s own documentation policy.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for a resident by not providing access to the call light. On multiple occasions, the resident was observed either in a wheelchair or in bed with the touch pad call light out of reach, including being wrapped around and clipped to a cord at the foot of the bed or lying on the floor. The resident confirmed being unable to reach the call light during an interview. Both RN 2 and the Director of Nursing acknowledged that the call light was not accessible to the resident. The resident's clinical record indicated diagnoses of severe protein calorie malnutrition and heart valve replacement. The facility's current policy required call lights to be accessible when in the room, but this was not followed in the observed instances.
MDS Assessment Failed to Reflect Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the hospice election status for a resident with a diagnosis that included acute kidney failure. Although a physician's order documented that the resident had been admitted to hospice, the annual MDS assessment indicated that the resident was not receiving hospice services. The MDS Coordinator confirmed that the resident had been on hospice for an extended period and acknowledged that the MDS assessment should have been updated to reflect this status. The Executive Director stated that the facility followed the RAI manual for MDS assessment accuracy, and a review of the manual confirmed the requirement to complete an MDS when a resident elects the hospice benefit.
Failure to Include Advanced Directive Preferences in Resident Care Plans
Penalty
Summary
The facility failed to ensure that person-centered, comprehensive care plans accurately reflected the advanced directive preferences for three residents. For each of these residents, clinical records and POST forms indicated clear advanced directive choices—either do not resuscitate (DNR) or full code (CPR)—which were documented and signed by the residents. However, upon review, the care plans for these residents did not include any section or information reflecting their advanced directive preferences, despite the presence of physician orders and POST forms specifying these choices. Interviews and policy review confirmed that the facility's protocol requires care plans to include measurable goals and resident-specific interventions based on individual needs and preferences, including medical directives. The Director of Nursing acknowledged that advanced directive preferences should be included in residents' care plans, but this was not done for the three residents reviewed. The deficiency was identified through observation, record review, and staff interview.
Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to update the advanced directive care plan for a resident after the resident changed their code status preference from Do Not Resuscitate (DNR) to full code status (CPR). The resident, who had a diagnosis including chronic obstructive pulmonary disease and was cognitively intact, had previously established a POST form indicating DNR status, which was reflected in the care plan. However, after a hospital discharge and a new POST form were completed, the resident's preference was changed to full code status, as confirmed by both the resident and documentation in the clinical record. Despite this change, the care plan was not revised to reflect the updated code status. The Director of Nursing acknowledged that the care plan should have been updated at the time of the change. Facility policy also indicated that care plans should be revised on an ongoing basis to reflect changes in the resident and the care being provided. The clinical record review confirmed the absence of a revised care plan addressing the resident's new code status preference.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Washington Healthcare Center | 4 mi | — | 10 | 0 |
| Envive Of Indianapolis | 5.1 mi | — | 15 | 0 |
| Forest Creek Village | 5.7 mi | — | 7 | 0 |
| Plainfield Health Care Center | 6.3 mi | — | 11 | 1 |
| Bethany Village | 6.3 mi | — | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.