Cycle 1
Health 2025-04-03 · Fire 2025-04-03
7 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Indianapolis, IN
Chalet Rehabilitation And Healthcare Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4851 Tincher Rd, Indianapolis, IN
(317) 856-4851
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Castle Healthcare
Operator or chain grouping
Approved since
1989-07-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.86
Licensed practical nurse staffing
Aide hours / resident day
1.79
Nurse aide staffing
Weekend hours
2.63
Weekend nurse staffing
RN turnover
17%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 22.1% |
93.6%
71.5 pts worse
|
93.4%
71.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 30.6% |
95.4%
64.8 pts worse
|
95.5%
64.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.8%
2.6 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 43.4% |
24.6%
18.8 pts worse
|
11.4%
32 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.7% |
5.6%
6.1 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
23.5%
11.9 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
14.8%
0.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.7% |
13.3%
7.6 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.5% |
11.7%
10.2 pts better
|
14.9%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
24.2%
4.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.1%
0.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.6% |
81.6%
62 pts worse
|
81.7%
62.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
10.5%
2.7 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 1.3% |
79.0%
77.7 pts worse
|
79.7%
78.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.9% |
22.4%
18.5 pts worse
|
23.9%
17 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-30 · Fire 2023-06-30
10 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-04-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-12
C · Minimal harm
2025-04-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-12
F · Potential for more than minimal harm
2024-06-28
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-08-17
F · Potential for more than minimal harm
2024-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-17
E · Potential for more than minimal harm
2024-06-28
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-08-17
D · Potential for more than minimal harm
2024-06-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-17
E · Potential for more than minimal harm
2023-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-06-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-06-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-02
C · Minimal harm
2023-06-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-28
D · Potential for more than minimal harm
2026-01-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-01-28
D · Potential for more than minimal harm
2026-01-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-04-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-01-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-09-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-06-30
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-07-25
C · Minimal harm
2023-06-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-04-17
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Andres, Anthony
Operational/Managerial Control · Individual
Berdugo, Shai
Operational/Managerial Control · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Clayshire LLC
Operational/Managerial Control · Organization
Decatur Real Propco LLC
5% Or Greater Mortgage Interest · Organization
Decatur Rehabilitation And Healthcare Center LLC
Operational/Managerial Control · Organization
Flueckiger, Russell
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Hughes, Edward
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Lt Care Acquisition Corp
Operational/Managerial Control · Organization
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Washington Healthcare Center
Indianapolis, IN
4-star overall rating with 3-star inspections with $14,518 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Envive Of Indianapolis
Indianapolis, IN
2-star overall rating with 1-star inspections with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Forest Creek Village
Indianapolis, IN
2-star overall rating with 1-star inspections with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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