Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 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.
A resident with adjustment disorder and a BIMS score of 13/15 became involved in a verbal altercation with a CNA after being told to go to the dining room. The resident later spoke with an LPN at the nurse’s station about being upset, and the CNA came over and argued with him, with both parties yelling and the CNA using profanity and statements such as not being a piece of sh**. Staff interviews confirmed the CNA was yelling and cursing around the resident.
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.
Unsafe Food Storage and Serving Practices: Surveyors observed multiple food safety issues in the kitchen, dining room pantry, freezer, and unit pantry, including unlabeled open cereal and bulk salt, an ice cream tub without an open date, expired berry juice, an open container of thickener, and the ice scoop stored in the ice machine. Staff also continued using moist trays, warming lids, and a plate during lunch service, and cereal was repeatedly found spilled under the dispensers. The Dietary Manager acknowledged several of the conditions, and 90 of 90 residents ate food from the kitchen.
Ceiling Tiles Left Stained and Damaged in Resident Areas: Multiple ceiling tiles in resident hallways and common areas were observed with brown and gray stains and visible cracks, including large stains near rooms, nurses stations, the medical records office, activity room, social services office, and the B-wing nurses station. Facility records reviewed did not show a current plan for replacing the soiled or damaged tiles, and the Administrator and RDO acknowledged the issue while noting replacement had been slowed by financial matters; a PIP for ceiling tile replacement was not available.
A resident with DM2, stroke history, and a BIMS score of 15 did not have complete MAR documentation showing ordered insulin and BG checks were given as prescribed. The record showed missing entries for Lantus, routine Novolog, and sliding scale Novolog, and refusals of Novolog were documented in progress notes but not properly reflected on the MAR with refusal codes and staff identifiers.
Failure to Notify Physician of Abnormal Catheter Findings: A resident with an indwelling catheter, CKD, and severe cognitive impairment had repeated observations of cloudy urine and sediment in the catheter tubing, including whitish sediment and very cloudy urine with large amounts of sediment. Although the resident had orders to monitor catheter color, clarity, and patency each shift and notify the MD of abnormal findings, staff did not document abnormal assessments, catheter flushes, or physician notification. RN and DON statements indicated the urine was considered normal for the resident, but this was not documented in the care plan.
The facility failed to provide trauma informed care for two residents. One resident had major depression, anorexia nervosa, and a PASRR noting a past suicide attempt, pain as a trigger for increased depression, and alcohol abuse history, but the care plan and Kardex did not include those trauma-related details and no Psychosocial Assessment or Abuse and Neglect Screening was found. Another resident with cerebral palsy, Down syndrome, depression, bipolar disorder, and impulse disorder had PASRR and screening information showing hallucinations, aggression, psychotic symptoms, and triggers such as rapid movement or contact, but the care plan and Kardex did not reflect those details despite repeated behavioral incidents and haloperidol use.
Unlabeled and improperly stored medications and supplies were found in the med room and in resident medication storage. An open bag of insulin syringes, staple removal kits, and catheter irrigation kits lacked required labeling and expiration dates, and a resident's nitroglycerin tablets were open with no open date noted. Two cups in a drawer contained unidentified pills, with one cup labeled with another resident's room number; staff stated the medications should have been discarded and that medications were not to be transferred between containers.
A resident with dementia and dysphagia was served the wrong meal from an unattended tray cart. The resident ate a whole bratwurst on a bun from another resident's tray, even though the tray card and orders indicated a mechanical soft diet with ground meat. An RN stated the cart should not have been left accessible and the tray card should have been checked before serving.
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.
Verbal Abuse During Argument at Nurse’s Station
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA. Resident B, who had a diagnosis of adjustment disorder and a BIMS score of 13/15 indicating he was cognitively intact, was involved in a verbal confrontation with CNA 2 after the CNA entered his room and told him and his roommate to go to the dining room for lunch. Resident B stated he did not go to the dining room and later spoke with an LPN at the nurse’s station about being upset with how CNA 2 had spoken to him. While Resident B was expressing his concerns at the nurse’s station, CNA 2 came around the corner and joined the interaction. Multiple staff statements and interviews described both CNA 2 and Resident B yelling at each other, with CNA 2 making statements including that she was not going to argue and that Resident B was not going to call her a piece of sh**. Resident B stated CNA 2 told him she was not a piece of sh** for him to talk to however he wanted, and the argument continued until other staff arrived. Staff interviews also confirmed that yelling, cursing, and arguing with or around residents was inappropriate.
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.
Unsafe Food Storage and Serving Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and serving practices during multiple observations of the kitchen, dining room pantry, freezer, and unit pantry areas. Surveyors observed open trays of cereal under dispensers in the dining room pantry with no labels, an open bag of white granules in a bulk salt bag with no label, an ice cream tub in the walk-in freezer with the lid only partially covering the product and no open date, an expired container of berry fruit juice in the B Hall pantry, the ice scoop stored in the ice of the unit ice machine with a broken hook nearby, and an open container of thickener liquid in the Garden Unit refrigerator without a lid or cover. The Dietary Manager stated the salt should be sealed and dated, and acknowledged the broken ice scoop hook. She also stated the resident and the resident's family would not be happy if the expired berry juice was thrown away. During later observations, surveyors again found cereal spilled and left under the dispensers in the dining room pantry. In the kitchen, paper towel rolls were observed sitting on top of the holders with moisture drops on the rolls after paper was torn off, a wall behind the sink had a missing tile exposing the wall, and stacked serving items had moisture in trays, warming lids, and a plate during lunch service while staff continued to use them. When the moist plate was pointed out, the [NAME] removed it. The Dietary Manager stated the missing tile had been entered into maintenance software and that housekeeping had not been putting the paper towels in the holders. A later observation again found about two cupfuls of cereal under the dispensers in the dining room pantry, and [NAME] 5 stated that 90 of 90 residents in the facility ate food provided by the kitchen.
Ceiling Tiles Left Stained and Damaged in Resident Areas
Penalty
Summary
The facility failed to maintain clean, intact ceiling tiles in 4 of 6 hallways where residents reside. During observation, multiple ceiling tiles throughout resident hallways and common areas were noted with brown stains, gray stains, and cracks, including tiles outside resident rooms, near the nurses stations, outside the medical records office, activity room, social services office, and near the aquarium by the B-wing nurses station. Several tiles had large stains ranging from about 5 inches to 24 inches, and multiple cracks were observed, including one tile with a crack about 14 inches long and another with five cracks around a return air vent. Documents reviewed, including the Touch Up Paint schedule, Deep Clean Schedule, and maintenance work orders for the last 30 days, did not include any current plan for replacement of soiled or damaged ceiling tiles. The Administrator stated that ceiling tiles should be intact and free of stains and indicated she would initiate replacement of damaged tiles. A later document listed ceiling tile replacements for the hall including rooms 114 through 129, but a subsequent observation showed the ceiling tiles remained unchanged. The Regional Director of Operations stated that some ceiling tiles had been replaced in April 2025, but other pressing financial matters had slowed the replacement process, and a performance improvement plan for ceiling tile replacement was not available for review.
Missing insulin administration and refusal documentation
Penalty
Summary
The facility failed to ensure that Resident 83 received insulin as ordered. Resident 83 had diagnoses including diabetes mellitus type 2, hemiplegia or hemiparesis, anxiety, and cerebrovascular accident, and the current quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact. The resident stated in interview that staff had missed insulin doses because the resident did not go out to the nurse’s station to receive them. Review of the June 2025 MAR showed missing documentation for multiple blood glucose checks and multiple insulin administrations, including Lantus, routine Novolog, and Novolog sliding scale coverage. The record also showed physician orders for blood glucose monitoring before meals and at bedtime, along with later insulin orders and sliding scale instructions. Progress notes documented that Resident 83 refused Novolog doses on 6/5/25, 6/17/25, and 6/30/25, but the June 2025 MAR was missing documentation for those refusals. An LPN stated that when a medication is refused, the provider should be called, the event documented in the EHR and MAR with a refusal code and staff identifier, and the NP notified; the LPN also stated there should not be missing information on the MAR. The facility policy on Documentation of Medication Administration stated documentation must include a reason why medication was withheld, not administered, or refused.
Failure to Notify Physician of Abnormal Catheter Findings
Penalty
Summary
The facility failed to notify the physician of abnormal catheter assessment findings for one resident with an indwelling catheter. The resident had diagnoses including chronic kidney disease and a Kennedy ulcer of the coccyx, and her MDS indicated severe cognitive impairment with a BIMS score of 1. During observations, her catheter tubing was noted to contain yellow cloudy fluid with sediment, later whitish sediment covering more than half of the tubing with light yellow cloudy fluid, and then light yellow urine that was very cloudy with large amounts of sediment. The resident had physician orders to monitor the indwelling catheter and urine for color, clarity, and patency every shift and to notify the physician of abnormal findings, as well as an order to irrigate the catheter with normal saline as needed for clogging or sediment. RN 5 stated abnormal urine could include dark or discolored urine, cloudiness, or sediment and that such findings should be reported to the provider, but she also stated the resident's urine appearance was normal for her and did not know whether it was documented. The DON stated normal urine would be clear and light yellow with no sediment or cloudiness, and that the resident always had cloudiness and sediment, but there was no documentation in the care plan that cloudy urine was normal for the resident. Review of the July 2025 records showed no documented catheter flushes, no abnormal urine assessments on the MAR/TAR, and no progress notes documenting abnormal assessments or physician notification.
Failure to Provide Trauma Informed Care
Penalty
Summary
The facility failed to ensure trauma informed care was provided for 2 of 3 residents reviewed. One resident had diagnoses including major depression, insomnia, nicotine dependence, and anorexia nervosa, with a PASRR noting a past suicide attempt, pain as a trigger for increased depression, and a substance disorder related to alcohol abuse or dependency. Although the resident’s care plan addressed alcohol abuse, psychosocial wellbeing, and anorexia nervosa, it did not include the history of attempted suicide or pain as a trigger for increased depression. The resident’s Kardex also omitted those trauma-related details, and the record did not contain a Psychosocial Assessment or an Abuse and Neglect Screening, despite staff stating trauma screening was completed on admission and added to the care plan. The second resident had diagnoses including cerebral palsy, Down syndrome, depression, bipolar disorder, affective mood disorder, and impulse disorder, with a PASRR noting hallucinations and a lower BIMS score. Prior psychosocial assessments identified increased anxiety and triggers of rapid movement or contact, and another assessment documented a physical altercation with another resident and agitation related to the resident’s mother not being able to take them home. An Abuse and Neglect Screening identified moderate problems with aggressive and agitated behavior, abuse or neglect, psychotic symptoms, and denial of mental health and psychosocial issues. However, the care plan did not include a history of delusions or hallucinations and did not identify rapid movement or contact as triggers. The resident’s record also showed multiple behavioral incidents in progress notes, including disruptive behavior in the dining room, swearing, attempting to hit staff, screaming, kicking the medication cart, throwing and grabbing items from the nurse station, agitation with broken glasses, yelling about a medical appointment, and biting a staff member. The resident received haloperidol injections during the month reviewed. The Kardex directed staff to follow PASRR recommendations and determine the underlying cause for behaviors, but it did not include the history of delusions or hallucinations. The DON stated the resident could possibly be triggered by upcoming medical appointments and could possibly have medical trauma, while the facility policy required identification of triggers that could re-traumatize residents and assessment through observation, interview, and screening tools.
Unlabeled and Improperly Stored Medications
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled or stored in accordance with accepted professional principles. During observation of the B wing medication room, an open bag of 30 insulin syringes was found in a drawer with no label showing when the pharmacy sent them to the building and no expiration date. The same room contained three staple removal kits, two of which had no label indicating when the facility received them and no expiration date, and one kit had an expiration date of 2-28-25. Two catheter irrigation kits stored in a container under a shelf were also observed without expiration dates and without labeling to show when they had been sent to the facility. RN10 stated she reviewed the medication room each Friday for expired and unlabeled supplies, and pharmacy checked the room about every other month. Medication storage issues were also observed for two residents. Resident 3's nitroglycerin tablets 0.3 mg were open with no open date noted on the label, although the pharmacy fill date was documented. In the top drawer, two clear cups contained a total of seven unidentified pills, and the bottom cup was labeled with Resident 71's room number. QMA 11 stated the medications were not set up by him and should have been discarded, and he reported that the prior nurse had been unable to administer medications that had already been set up because the resident had left the building for an appointment. The facility policy on medication labeling and storage stated that opened or accessed medications would be dated and discarded with 30 days of opening and that medications would not be transferred between containers.
Incorrect mechanically altered diet served from unattended tray cart
Penalty
Summary
The facility failed to ensure that a mechanically altered diet was served as ordered for one resident with dementia and dysphagia. During a dining observation on the dementia unit, the resident reached into an unattended meal tray cart, pulled out a tray, lifted the plate cover, and began eating a bratwurst sausage on a bun that was whole and not chopped or ground. An RN then approached, read the tray card, and moved the resident to the table with the remaining items from the tray. The RN stated the tray had been prepared for another resident and said it was not an issue because both residents were on the same diet. When the RN later pulled the tray prepared for the resident, it contained a bun filled with ground bratwurst, and the tray card identified the resident as needing a mechanical soft diet with ground meat. The RN also stated the tray cart should not have been unattended and accessible, the tray card should have been checked before serving, and the resident should have received ground meat as ordered. The resident's record showed diagnoses of dementia and dysphagia, an MDS indicating a mechanically altered diet, and orders for a regular diet with mechanical soft texture and food served in individual bowls, one bowl at a time.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 303 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 7 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.