Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
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 Chateau Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow ordered pressure ulcer treatments for two residents with chronic pressure injuries. One resident with paraplegia and an unstageable ischial/buttock wound had NP orders for calcium alginate with Santyl three times daily, and later wound clinic orders for specific dressings to the buttock and sacrum, but the TAR showed only once-daily Santyl-based treatments and no implementation of the wound clinic’s regimen. Another resident with a stage 4 sacral pressure injury and osteomyelitis had wound clinic orders for Endoform AM with a bordered superabsorber dressing every other day, yet the TAR documented ongoing use of collagen with silver and daily Vashe-soaked gauze instead. Leadership interviews confirmed that wound NP and wound clinic orders were supposed to be followed as written and placed on the TAR, but staff did not update and carry out the treatments as ordered.
A resident with paraplegia and an Indiana pouch required straight catheterization every 4 hours, with staff instructed to offer assistance, especially at night, and to document urine output and monitor for UTI signs. On one day, scheduled catheterizations were not completed at two time points, no urine output was recorded, and there was no documentation explaining the missed catheterizations. Later that day, the resident was noted to be lethargic with a distended, painful abdomen, staff were unable to catheterize the pouch, and the resident was sent to the ER, where 2 liters of urine with mucus and blood were drained and labs showed leukocytosis, acute kidney injury, urinary retention, and hyponatremia. The DON reported being unaware that catheterizations had not been done or documented, despite a facility policy requiring monitoring of residents with Indiana pouches and reassessment of self-care ability with changes in condition.
A resident with end stage renal disease, chronic pain, and diabetes experienced significant changes in condition, including refusal of dialysis and medications, altered mental status, and suspected alcohol use. Staff failed to document these events and did not notify the physician or dialysis team as required by facility policy, resulting in a lack of timely medical intervention.
A resident with dementia and other comorbidities developed significant pressure injuries, including an unstageable coccyx wound and black wounds on both heels, after the facility failed to update care plans, document wound progression, and implement individualized interventions despite changes in mobility and incontinence. Wound care recommendations were not consistently incorporated, and the extent of the wounds was not communicated to the receiving facility or family at discharge.
The facility was found deficient in maintaining cleanliness in ceiling return air ducts, with three out of ten vents observed to have gray, feathery debris. The vents were located in Hall 100, including the memory unit and near the nurse's station. The Administrator confirmed that the vents should be debris-free, but the facility's Deep Clean List did not include cleaning instructions for these intakes.
A facility failed to conduct a comprehensive assessment and implement non-pharmacological approaches before reducing a resident's antipsychotic medication. The resident, with a history of dementia and behavioral disturbances, experienced increased agitation and aggression following the medication reduction, leading to a fall and hip fracture. The facility did not document non-pharmaceutical interventions or obtain family consent for the medication change.
The facility failed to ensure their registered dietician was licensed in Indiana, as required for providing dietary services. The dietician, hired in June 2024, was licensed in other states but not in Indiana. This deficiency was identified during a review of employee records and confirmed by the Indiana Professional Licensing Agency's website, which mandates state licensure for dieticians.
A facility failed to record and communicate fall interventions for a resident with Alzheimer's and other conditions, leading to multiple undocumented falls. Despite a history of falls and risk factors, interventions were inconsistently documented, and care plans were outdated and inaccessible to staff, contributing to inadequate supervision and fall prevention.
The facility failed to clean a shared glucometer between uses for three residents, leading to a breach in infection control practices. An LPN used the glucometer for multiple residents without disinfecting it, contrary to facility policy. The residents involved had serious health conditions, including diabetes and renal disease. The facility's policy requires cleaning the glucometer with a disinfectant wipe before and after each use, which was not followed.
A resident with multiple medical conditions was found to have a significant area of missing floor paneling near their bed. Staff, including RNs and CNAs, were unaware of the damage until it was observed, and maintenance was not informed prior. The facility uses an application for reporting maintenance issues, but the damage was not reported through this system.
Failure to Follow Ordered Pressure Ulcer Treatments for Two Residents
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for two residents with pressure injuries. For one resident with paraplegia and chronic pressure-related wounds, an in-house wound NP documented an unstageable left ischial wound measuring 20 cm x 16 cm x 1 cm with specific orders to clean the wound, apply calcium alginate with Santyl to the wound base, and secure with a bordered dressing three times per day. The January Treatment Administration Record (TAR) showed that from the beginning of the month through multiple days, Santyl was applied only once daily to a left buttock wound and the left ischium was treated once per day with Santyl and calcium alginate, rather than three times per day as ordered. A subsequent wound clinic note documented two wounds (left buttock and sacrum) with new treatment orders for each, but the TAR continued to reflect the prior regimen and did not show that the wound clinic’s specific dressing orders were implemented. Later NP documentation again referenced only a sacral wound with the same measurements as the earlier ischial wound, and an LPN clarified that the measured area included the left buttock, indicating inconsistency between documentation and ordered treatments. For another resident with a chronic stage 4 sacral pressure injury and osteomyelitis of the coccyx, a wound clinic note ordered cleansing with baby soap and water, followed by application of Endoform AM and coverage with a bordered superabsorber dressing, with dressing changes every other day. Manufacturer information described Endoform AM as an antimicrobial dressing for acute and chronic wounds that can remain in place for several days and is to be changed per physician order. However, the January TAR showed that throughout the month the resident’s sacral wound was treated instead with collagen with silver placed in the wound bed three times weekly, along with daily Vashe-soaked gauze and bordered gauze, with collagen applied first and Vashe gauze over it. The TAR did not reflect implementation of the wound clinic’s Endoform AM orders. In interviews, the ADON and DON confirmed that wound care orders from either the in-house wound NP or the wound clinic were to be followed as written and placed on the TAR, and the Administrator acknowledged that staff had missed changing the wound treatments as ordered, contrary to the facility’s wound care policy requiring wound care to be done as ordered by the physician.
Failure to Monitor and Assist With Indiana Pouch Catheterization Leading to Acute Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary assessment, monitoring, and assistance with catheterization for a resident with an Indiana pouch, resulting in hospitalization for sepsis. The resident had diagnoses including paraplegia, an Indiana pouch (continent urinary reservoir), pressure-related wounds, and chronic pain syndrome treated with routine pain medications. Her care plan indicated she required some assistance with ADLs due to paraplegia, muscle wasting, and intermittent catheterization, and specified that straight catheterization of the Indiana pouch was to occur every 4 hours. Although the resident was considered competent to self-catheterize, the care plan and physician orders directed staff to offer assistance with catheterization every 4 hours, especially at night, document urine output, and observe for signs and symptoms of UTI. On the date in question, the Treatment Administration Record showed that scheduled catheterizations at 8:00 a.m. and 12:00 p.m. were not completed and no urine output was recorded. The nurse’s initials and notation to refer to progress notes were present, but there were no corresponding progress notes during that time frame explaining why catheterization was not done or why there was no output. Later that afternoon, a progress note documented that the resident had been lethargic during the day, and when the nurse went to change dressings, the resident’s abdomen was observed to be distended and painful. The nurse attempted to assist the resident with catheterizing the pouch but was unsuccessful, and the on-call NP was notified with orders to send the resident to the ER for mental status change, distended abdomen, inability to catheterize, and wound changes. Hospital records documented that the resident reported abdominal pain beginning around lunchtime and decreased appetite over the preceding days. She stated she self-catheterized her Indiana pouch but had not obtained any urine that day and had been unable to remove urine since the previous night. Examination revealed a distended abdomen, and after gentle dilation of the urostomy, a catheter was placed and 2 liters of urine with large amounts of mucus and blood were drained from the pouch. Laboratory results showed a markedly elevated WBC, positive urine for blood, WBCs, and bacteria, low sodium, and elevated creatinine, and she was admitted for leukocytosis, acute kidney injury, urinary retention, and hyponatremia. The DON later indicated she was not aware that catheterizations had not been performed or documented earlier that day, and acknowledged there should have been documentation in the TAR or progress notes explaining why catheterization was not done. The facility’s Indiana pouch management policy required assessment of the resident’s ability to perform self-care with any change in condition and nursing monitoring for changes in continence and signs of infection or complications.
Failure to Notify Physician and Dialysis Team of Resident's Change in Condition and Refusal of Treatment
Penalty
Summary
The facility failed to ensure timely and appropriate notification of a resident's physician and dialysis team regarding significant changes in the resident's condition and refusal of treatment. The resident in question had end stage renal disease requiring dialysis, chronic pain managed with opioids, and diabetes, and was noted to have moderately impaired cognition. On multiple occasions, staff observed the resident to be out of sorts, smelling of alcohol, refusing dialysis, and refusing medications, but there was a lack of documentation and communication with the medical team regarding these changes. Specifically, after the resident was noted to smell of alcohol, an order was obtained for a drug and alcohol screen, but the resident refused the test. This refusal was not documented in the medical record, nor was the nurse practitioner or dialysis team notified of the refusal. Additionally, when the resident refused dialysis and medications and exhibited altered consciousness, there was no documentation of nursing assessment or notification to the medical team about the held medications or the resident's ongoing condition. The nephrologist confirmed that neither she nor her staff were informed of the resident's possible intoxication or altered mental status prior to the next dialysis session. Facility policy required immediate notification of physicians for acute problems or significant changes in resident status, with appropriate assessment and documentation. However, the facility did not follow these guidelines, as evidenced by the lack of timely communication and documentation regarding the resident's refusal of treatment, changes in condition, and the holding of medications. This deficiency was identified through interviews, record reviews, and policy examination.
Failure to Assess, Document, and Intervene for Pressure Ulcers
Penalty
Summary
A resident with a history of dementia, major depressive disorder, and chronic obstructive pulmonary disease was admitted to the facility from an inpatient psychiatric hospital. Upon admission, the resident was assessed as not being at risk for pressure ulcers and had no current skin impairments. However, over the course of her stay, the resident developed significant skin issues, including large blisters on both heels and eventually a pressure injury to the coccyx. Despite changes in her mobility, increased incontinence, and the development of pressure injuries, the care plan was not updated to reflect these changes or to include new interventions as recommended by wound care specialists and as indicated by skin assessments. The facility failed to consistently document and assess the resident's wounds. Although wound care consultations and recommendations were made, such as the use of heel protectors, barrier creams, and turning protocols, these were not always incorporated into the care plan or consistently documented in the medical record. There was also a lack of detailed wound measurements and descriptions, particularly regarding the coccyx wound, and no evidence that the wound nurse practitioner was notified of the open area on the coccyx. Orders for wound treatments were given, but staff interviews revealed confusion about the presence and treatment of the coccyx wound, and the wound was not properly tracked or communicated. Upon discharge to another facility, the resident was found to have an extensive, unstageable pressure injury to the coccyx with foul odor and slough, as well as black wounds on both heels. The receiving facility and the resident's family were unaware of the extent of the wounds prior to transfer. Documentation from the sending facility did not accurately reflect the resident's wound status at discharge, and there was no indication that the care plan had been updated to address the new and worsening wounds. The lack of timely assessment, documentation, and individualized interventions led to the worsening of the resident's pressure injuries.
Facility Fails to Maintain Clean Ceiling Air Ducts
Penalty
Summary
The facility failed to maintain cleanliness in the ceiling return air ducts, as observed during an environmental tour. Specifically, three out of ten vents were found to have gray, feathery debris. These vents were located on Hall 100 south of the dining room, on the memory unit, and by the nurse's station. During an interview, the Administrator acknowledged that the ceiling air intake vents should be free of debris. However, a review of the facility's undated Deep Clean List revealed that it did not include instructions for cleaning the ceiling air intakes. This deficiency was related to a complaint identified as IN00448990.
Failure to Implement Comprehensive Assessment Before Medication Reduction
Penalty
Summary
The facility failed to ensure a comprehensive assessment and evaluation, along with non-pharmacological approaches, were identified and implemented before decreasing a resident's antipsychotic medication. Resident B, who had a history of dementia with behavioral disturbances, anxiety disorder, and severe malnutrition, was admitted to the facility with a fractured left ankle and was on Zyprexa for psychosis. Despite the psychiatric physician's recommendation to continue Zyprexa, the facility's interdisciplinary team decided to reduce the medication without proper documentation of non-pharmaceutical interventions or family consent. On the day following the medication reduction, Resident B exhibited agitation and aggressive behavior, which led to an incident where she threw silverware at staff and subsequently fell, resulting in a right hip fracture. The facility's records lacked documentation of delusions or other behaviors that would justify the reduction of Zyprexa. Furthermore, there was no evidence that the resident's family was informed or agreed to the medication change, nor was there a comprehensive treatment plan in place to address her behavioral symptoms. The facility's policy on medication management and psychotropic agents was not adhered to, as there was no comprehensive regimen review or appropriate gradual dose reduction assessment. The psychiatric NP involved in the decision to reduce the medication did not have access to the resident's hospital records and had not evaluated the resident before the medication change. This lack of communication and documentation contributed to the resident's adverse event and subsequent hospitalization.
Dietician Licensing Deficiency
Penalty
Summary
The facility failed to ensure that their registered dietician was licensed in the state of Indiana, which is a requirement for providing dietary services. The review of employee records revealed that the registered dietician, hired on June 1, 2024, did not possess an Indiana license. Instead, the dietician was licensed in North Carolina, South Carolina, and Florida. This oversight was identified during a record review and interview process conducted on August 18 and 19, 2024. The Indiana Professional Licensing Agency's website confirmed that, effective July 1, 2019, dieticians must be licensed through the Medical Licensing Board of Indiana. Despite this requirement, no Indiana license was found for the dietician in question. The facility's policy, dated November 2021, also stipulated that a qualified dietician must be licensed in the state where services are performed. The administrator acknowledged the federal regulation requiring state licensure for dieticians, yet no Indiana license was provided for the dietician by the time of the survey exit.
Failure to Record and Communicate Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were recorded and communicated for a resident with Alzheimer's disease, major depressive disorder, and unilateral primary osteoarthritis of the right hip. The resident's record indicated a history of falls and various risk factors, including disorientation, incontinence, decreased muscular coordination, and medication side effects. Despite multiple falls occurring between May and August, interventions were inconsistently documented and communicated. For instance, after a fall on May 18, no interventions were recorded, and subsequent falls on June 23 and July 5 also lacked detailed descriptions or interventions. The care plan and Kardex were not updated promptly, and staff were unaware of the current interventions due to outdated care plan documentation. During an observation and interview, it was revealed that the care instructions for residents were outdated and not easily accessible to staff. The care plan book contained information for residents no longer residing in the unit, and the current care plan for the resident in question was missing. The facility's policy required that new interventions be implemented immediately after a fall and communicated to staff, but this was not consistently done. The lack of updated and accessible care plans contributed to the failure in providing adequate supervision and fall prevention for the resident.
Failure to Clean Shared Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices by not cleaning a shared glucometer between uses for three residents. During a medication pass observation, an LPN used a glucometer to check the blood glucose level of a resident without cleaning it before or after use. The glucometer was then returned to the medicine cart and used for other residents without disinfection. The LPN admitted to not cleaning the device, mistakenly believing another employee had done so. The facility's policy requires glucometers to be cleaned with a disinfectant wipe for a specified duration before and after each use to prevent cross-contamination. The residents involved in this deficiency included individuals with type 2 diabetes and other serious health conditions such as chronic kidney disease, end-stage renal disease, and heart failure. The residents' mental status varied, with some being cognitively impaired and others intact. The facility's policy and the administrator confirmed the requirement for cleaning the glucometer to prevent cross-contamination, but this was not adhered to during the observed medication pass.
Failure to Maintain Safe Flooring for Resident
Penalty
Summary
The facility failed to ensure that the flooring panels were complete and intact for one of the residents reviewed. During an observation, a significant area of floor paneling was found missing in front of the heating unit and near the end of the resident's bed. A loose floor panel was lying across a portion of the uncovered area. The resident involved had multiple medical conditions, including multiple sclerosis, unspecified dementia, and type 2 diabetes mellitus, and was cognitively impaired with a Basic Interview for Mental Status (BIMS) score of 4. Staff members, including a registered nurse and certified nurse aides, were unaware of the floor damage until it was pointed out during the observation. The maintenance staff also indicated that this was the first time they were informed of the issue. The facility's administrator stated that floor damage should be reported through the facility maintenance system immediately upon discovery. However, there was no record of the damage being reported prior to the observation, and the facility's current method of communication regarding maintenance issues was through an application called tells, as indicated in the Point Click Care Dashboard.
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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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Fort Wayne Skilled Nursing Facility, The | 0.5 mi | — | 5 | 0 |
| Golden Years Homestead | 1.4 mi | — | 1 | 0 |
| Celebrate Senior Living Of Fort Wayne | 1.8 mi | — | 12 | 0 |
| Heritage Park | 1.9 mi | — | 7 | 0 |
| Byron Health Center | 2.2 mi | — | 15 | 0 |
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