Indiana State Department of Health
Division of Long Term Care
 
CONSUMER REPORT
 
CHALET VILLAGE HEALTH AND REHABILITATION CENTER
 
NURSING HOME
SKILLED NURSING FACILITY / NURSING FACILITY DUALLY CERTIFIED
Created on: 06/08/2018
 
Posted to the Web on: 06/20/2018
 
 



Basic Information

FACILITY CONTACT INFORMATION:
Address: 1065 PARKWAY ST
City: BERNE
Telephone: (260) 589-2127
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 17-000546-1
  License effective date: 11/01/2017
  License expiration date: 10/31/2018
 


Administration and Staff

Administrator: MELINDA HODGSON
  Start date: 04/13/2017
 
Director of Nursing: SHAWNA MICHEL
  Start date: 12/20/2014
 
Medical director:  
  Start date:   /  /  
 
Wound care specialist:  
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 


Ownership

CURENT OWNERSHIP:
 
Owning corporation: BOARD OF TRUSTEES OF THE FLAVIUS J WITHAM MEMORIAL
2605 NORTH LEBANON STREET
LEBANON IN 46052
 
Ownership type:  OTHER
 
Officer(s): MARGARET MCFRYE
            NANCY MORTON
            BEVERLY NEWHART
            RAYMOND INGHAM
            GEORGE POGAS
            STEPHEN BARDOCZI
            C ARCHIBALD HAWKINS
            JACK JONES
            JOHN BRAND
 
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: MAGNOLIA HEALTH SYSTEMS XII LLC
Date of last change of ownership: 11/01/2011
 


Bed Counts and Census

COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF):                     0
Number of Medicare beds (SNF):                    0
Number of Medicare/Medicaid beds (SNF/NF):        80
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     80
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            0
 
Total number of beds in facility:            80
 
CENSUS:
Facility census:  27
As reported by the facility on: 01/02/2018
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/02/2018
 
Residential care beds occupied:  0
As reported by the facility on: 01/02/2018
 
Alzheimer Beds:  0
Alzheimer Beds Occupied:  0
As reported by the facility on:   /  /  
 
Ventilator Beds:  0
Ventilator Beds Occupied:  0
As reported by the facility on:   /  /  
 


Sprinklers and Smoke Detectors

This facility is: FULLY SPRINKLERED
 
Number of comprehensive care resident rooms: 38
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 38
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 0
 
Person completing form - MELINDA SUE HODGSON
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. ADMINISTRATOR
Date form completed - 02/22/2018
 


Nurse Aide Training

NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 10/07/2016
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2020
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 03/06/2013
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     NORTH ADAMS VOCATIONAL SCHOOL
         Approved: 07/10/2006
         Terminated: 08/01/2006
     CHALET VILLAGE HEALTH AND REHABILITATION CENTER
         Approved: 10/07/2016
         Terminated: N/A
     UNIVERSITY OF SAINT FRANCIS
         Approved: 10/30/1997
         Terminated: 04/02/2002
     TWIN CITY HEALTH CARE
         Approved: 04/12/2018
         Terminated: N/A
 


Complaints

NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  0
  Previous year:  0
  2 years previous:  0

 


Facility Report Card



 
   We are experiencing technical issues with the consumer report card system.
   We are working to resolve the issue.

 
The statewide average line is being provided to give you a reference
for looking at the scores of the selected facility.  This row 
contains the mean average calculated scores for all facilities as of
above date resulting in a scoring range of 0 to 587.
Scores are considered to be better the closer to zero they are.
Percentile rank of 100 represents the lowest report card score or best performing facility,
with a rank of 1 being the highest report card score.
 
View the Scope and Severity grid
 
View the scoring methodology
 



Overview of Survey findings




 
 The Most Recent Set
 2ND Most Recent Set
 3RD Most Recent Set

Immediate Jeopardy
No
No
No


 Substandard Quality of Care 
No
No
No


Administrator Change
Yes
No
No


Owner Change
No
No
No


Number of Substantiated Complaints With Deficiencies
0
0
0


Deficiency Free Standard Health Survey
No
No
No


 
    The term 'Recent Set' referenced above relates to the referenced annual survey,
    and any other surveys performed between it and the previous annual survey.
 

 


Enforcement Actions

Event ID: 8QVF11
  Notice to facility: 08/13/2002
             Appeal: 08/21/2002
  Action Cease/Recind: 07/28/2004
         Case Closed: 07/28/2004
  Initial Amount: $0
Event ID: GSG011
  Action - Citation / Fine
  Notice to facility: 11/08/2000
             Appeal: N/A
  Action Cease/Recind: 01/10/2001
         Case Closed: 01/10/2001
  Initial Amount: $1875
 
Federal Certification Actions Imposed
 
Date terminated from Medicare/Medicaid: N/A
 


Survey History


    The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
    The survey report therefore will likely not be posted until four to six weeks after the exit date.
        
    In the grid below click on an event ID that is underlined to see the survey report for that event.

        
          

          

 
Event ID
Survey Type
Exit Date

PZCB22
Follow Up, Life Safety Code, Recertification
02/02/2018


PZCB21
Recertification, Life Safety Code
11/29/2017


PZCB12
Recertification, Follow Up, State Licensure
11/07/2017


PZCB11
Recertification, State Licensure
10/10/2017


268M11
Complaint
05/10/2017


5HPN22
Recertification, Follow Up, Life Safety Code
10/20/2016


8UIY11
Complaint
09/15/2016


5HPN12
Recertification, Follow Up, State Licensure
09/09/2016


5HPN21
Life Safety Code, Recertification
08/25/2016


5HPN11
Recertification, State Licensure
08/09/2016


LLXS11
Complaint
06/20/2016


MT1612
Complaint, Follow Up
01/21/2016


MT1611
Complaint
12/22/2015


J53K12
Complaint, Follow Up
11/30/2015


J53K11
Complaint
10/27/2015


6GCJ22
Follow Up, Life Safety Code, Recertification
10/02/2015


6GCJ12
Recertification, Follow Up, State Licensure
09/02/2015


6GCJ21
Life Safety Code, Recertification
08/13/2015


6GCJ11
Recertification, State Licensure
08/03/2015


 
 


Links and Resources

 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
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