Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Valparaiso Care & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure that ordered medications and accuchecks were consistently administered and properly documented for several residents. A resident with diabetes and neuropathy missed multiple scheduled doses of gabapentin and hydroxyzine without any recorded reason. Another resident with diabetes did not receive ordered daily Lantus and Novolog insulin on multiple occasions, and ordered twice-daily accuchecks were not completed as prescribed, with no documentation explaining the omissions. A cognitively intact resident with hypothyroidism had multiple days over several months where her ordered morning levothyroxine was not signed off as given on the MAR. In all cases, there was no supporting documentation in the MAR or nurses’ notes to explain the missed or unsigned doses.
Surveyors observed that the facility exceeded the acceptable medication error rate when three dosing errors occurred during 27 observed medication administrations. In one case, an LPN prepared only one 10 mg tablet of metoclopramide instead of the ordered 20 mg dose for a resident with type 1 diabetes. In another case, an LPN prepared only one 625 mg Fiberlax tablet and one 325 mg acetaminophen tablet instead of the ordered 1250 mg Fiberlax and 650 mg acetaminophen for a resident with dementia and osteomyelitis. In both instances, the LPNs initially indicated the medications were ready to administer and were stopped before administration, and the errors conflicted with physician orders and the facility’s policy requiring adherence to the five rights of medication administration.
A resident’s clinical record was incomplete and inaccurate when staff failed to document a voiced allegation of abuse and related behaviors. An incident report and internal investigation showed that the resident had accused staff of abuse and had been yelling and using vulgar language, as reported by CNAs and LPNs. Despite this, there was no entry in the progress notes describing the allegation or the behaviors. One LPN believed another LPN was handling the documentation, while the other LPN did not chart the event because it was not personally witnessed, resulting in missing required documentation in the medical record.
A resident with cerebral palsy, a G-tube, and two unstageable pressure ulcers was observed receiving Jevity 1.5 at 45 cc/hr, even though the RD had recommended, and the physician had ordered, a continuous rate of 55 cc/hr to better meet nutritional and fluid needs. Care plans identified the need for enteral feeding to support wound healing and specified that tube feedings should be given as ordered. The MAR documented the feeding as being given at 55 cc/hr on multiple shifts, which conflicted with surveyor observations, and there was no documentation of tube feeding on one day shift. This was inconsistent with the facility’s policy requiring licensed nurses to implement physician orders for enteral therapy.
During construction in a dementia unit, accident hazards such as ladders, drop cloths, and power tools were left in a hallway accessible to mobile residents without staff supervision. Additionally, sit-to-stand lifts on multiple units were found with dirty wheels and debris buildup, as confirmed by both resident feedback and environmental inspection. Staff cleaning practices focused on high-touch areas, leaving other parts of the equipment uncleaned.
The facility failed to properly store and label insulin on two medication carts. Insulin pens and vials were found without open dates or past the disposal period. Staff interviews confirmed the insulins should have been dated and disposed of within 30 days, as per facility policy.
A resident expressed concerns about privacy in a shared bathroom with two male residents in an LTC facility. Although she did not use the toilet due to continence issues, she felt uncomfortable using the bathroom for washing, fearing a male resident might enter. The resident, who was cognitively intact, had not previously reported these concerns to the staff.
The facility failed to update care plans for two residents, leading to inaccuracies in their medical records. One resident's care plan still indicated a need for contact isolation due to a resolved MRSA infection, while another resident's care plan inaccurately documented her dialysis access site. These discrepancies were confirmed through interviews and record reviews.
A facility failed to monitor and treat a resident with edema and did not ensure proper documentation and administration of medications for two other residents. A resident with swollen legs reported the condition, but there was no documentation or physician notification. Additionally, two residents had missing documentation for medication administration, with the DON suggesting scheduling issues and claiming procedures were followed despite the lack of records.
A facility failed to properly flush a PICC line with the required 10 cc of normal saline before administering an antibiotic to a resident. The Infection Preventionist only used 6 cc of saline, contrary to the physician's order and facility policy. The error was acknowledged by the IP during an interview.
A resident with Parkinson's disease and COPD received incorrect respiratory care when observed with an oxygen flow rate set at 4 lpm instead of the prescribed 2 lpm. Additionally, the humidity bottle on the oxygen concentrator had not been changed weekly as ordered. The resident required substantial assistance due to moderate cognitive impairment, and the deficiency was confirmed by the Cottage Unit Manager.
A facility failed to monitor a resident's dialysis access site as required. The resident, who was cognitively intact, had a right upper arm graft for dialysis access. The care plan required monitoring for complications every shift, but the MAR and TAR lacked documentation of such monitoring. The Physician's Order Summary did not specify the location for monitoring bruit and thrill, nor did it include orders for other potential complications. The DON acknowledged the need to clarify orders for proper monitoring.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a PICC during medication administration. The Infection Preventionist (IP) did not use proper signage or personal protective equipment and failed to change gloves or perform hand hygiene after reaching into her pocket. The resident's records lacked physician's orders for EBP, and the Director of Nursing confirmed the oversight. Facility policy required EBP for residents with indwelling medical devices.
Failure to Administer and Document Ordered Medications and Accuchecks
Penalty
Summary
The facility failed to administer medications and blood glucose testing (accuchecks) as ordered and failed to document reasons for missed doses for multiple residents. One resident with diabetes mellitus and neuropathy had physician orders for gabapentin 400 mg four times daily and hydroxyzine HCL 25 mg every six hours. Review of the MAR from mid-March to mid-April showed gabapentin was not administered at least twice and hydroxyzine was not administered at least twice, with no documentation on the MAR or in nurses’ progress notes explaining why the medications were not given. This resident reported during interview that she did not always receive her medications as ordered. Another resident with diabetes mellitus had orders for daily Lantus insulin at 9:00 a.m., daily Novolog insulin at 8:00 a.m., and accuchecks twice daily at 6:00 a.m. and 4:00 p.m. The MAR indicated that both Lantus and Novolog insulin were not administered on at least two dates, and the 4:00 p.m. accucheck was not completed on at least two dates, with no documentation explaining the omissions. A third resident with hypothyroidism and documented as cognitively intact had an order for levothyroxine 50 mcg every morning. MARs for several consecutive months showed blanks on multiple dates where levothyroxine was not signed off as given. In each case, the DON was unable to provide further information, and there was no documentation to account for the missed or unsigned medication administrations, despite a facility policy requiring medications to be administered with the right resident, medication, dose, time, and route.
Medication Pass Errors Result in Exceeded Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying three errors during 27 observed medication administration opportunities, resulting in an 11.1% error rate. In one instance, an LPN prepared a 4:00 p.m. dose of metoclopramide for a resident with type 1 diabetes by placing only one 10 mg tablet in the medication cup. The LPN initially indicated the medication was ready to administer and was stopped prior to entering the resident’s room, at which point she acknowledged that the physician’s order required a 20 mg dose, meaning two tablets should have been prepared. The resident’s record confirmed a physician’s order for metoclopramide 20 mg to be administered four times daily at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. In another instance, an LPN prepared a morning medication pass for a resident with dementia and osteomyelitis and placed only one 625 mg Fiberlax tablet and one 325 mg acetaminophen tablet into the medication cup, along with other medications. The LPN stated the medications were ready to administer and was stopped prior to administration, then acknowledged that there should have been two tablets of Fiberlax (for a total of 1250 mg) and two tablets of acetaminophen (for a total of 650 mg) in accordance with the physician’s orders. The resident’s record showed an order for Fibercon (Fiberlax) 625 mg, 1250 mg twice daily, and acetaminophen 325 mg, 650 mg twice daily. The facility’s medication administration policy, dated 4/2025, required adherence to the five rights of medication administration: right resident, right medication, right dose, right route, and right time.
Failure to Document Abuse Allegation and Resident Behaviors in Clinical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident when it did not document an allegation of abuse and associated behaviors in the resident’s medical record. An Indiana Department of Health incident report indicated that Resident B voiced an allegation of abuse against staff, and an undated internal investigation showed that interviews were conducted with two CNAs and two LPNs, who reported that the resident had been yelling and calling staff vulgar names. However, there was no corresponding documentation in the resident’s progress notes regarding the voiced allegation or the resident’s behaviors at the time of the incident. During interviews, one LPN stated she believed another LPN was responsible for completing the documentation, while the other LPN indicated she had not charted the incident because she had not personally witnessed it. As a result, the resident’s clinical record did not reflect the reported allegation of abuse or the behavioral observations described by staff, contrary to requirements to maintain clinical records in accordance with accepted professional standards.
Failure to Administer and Document Tube Feeding at Ordered Rate for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to administer and document gastrostomy tube feedings at the physician-ordered rate for a resident with unstageable pressure ulcers. Surveyors observed on multiple occasions that the resident’s Jevity 1.5 tube feeding was infusing at 45 cc/hr, despite a physician’s order dated 2/17/26 specifying a continuous rate of 55 cc/hr. The resident’s care plans, both dated 2/3/26, identified the need for enteral feeding to meet nutritional needs and specifically referenced unstageable pressure ulcers on the left buttock and left ischium present on admission, with interventions stating that enteral feeding would be administered as ordered by the physician. Record review showed that the RD’s progress note on 2/9/26 documented an initial tube feeding rate of 45 cc/hr with water flushes and recommended increasing the rate to 55 cc/hr to better meet estimated protein and fluid needs for the resident, who had cerebral palsy and a gastrostomy tube and was receiving more than half of their nutrition and fluids via the tube. A physician’s order was subsequently written to increase the rate to 55 cc/hr. However, the MAR for 2/2026 indicated the tube feeding was documented as being administered at 55 cc/hr on 2/18/26 for all shifts, which conflicted with surveyor observations of a 45 cc/hr rate, and there was no documentation of tube feeding administration on the 2/19/26 day shift. The facility’s feeding tube policy required licensed nurses to implement physician orders for enteral therapy, which was not followed in this case.
Failure to Maintain Safe and Sanitary Environment During Construction and Equipment Use
Penalty
Summary
The facility failed to maintain a sanitary, safe, and homelike environment during ongoing construction in the dementia unit and in the maintenance of resident care equipment. On observation, the hallway to resident rooms in the Cottage Dementia Unit was found to have multiple accident hazards, including drop cloths, ladders, and power tools left on the floor while construction was underway. The fire doors to the hallway were closed, and there were no windows to see into the hallway. Several residents, three of whom were mobile and could walk unassisted or with a walker, were in their rooms with no staff present in the hallway or rooms to assist them if they exited. Facility staff confirmed that residents could access the hallway during construction, and there was no staff stationed to ensure their safety amid the hazards. Additionally, during a group resident council interview, residents reported that sit-to-stand lifts needed cleaning, specifically noting dirty wheels with hair stuck in them. An environmental tour confirmed that lifts on both the East Wing and another unit had dried substances, crumbs, and significant hair and debris buildup in the wheels. The Maintenance Supervisor acknowledged that CNAs typically cleaned the lifts between uses but focused mainly on handles and high-touch areas, leaving other parts uncleaned.
Improper Storage and Labeling of Insulin on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, specifically insulin, on two of the four medication carts observed. On the East Cart, several insulin pens, including Basaglar KwikPen and Toujeo SoloStar, were found either with no open date written on them or past the 30-day disposal period after opening. During an interview, the East Unit Manager acknowledged that the open insulins should have been dated and disposed of 30 days after opening, as per the facility's policy. Similarly, on the Cottage Cart, insulin lispro and Lantus pens were found without open dates, and an insulin lispro vial was past the 30-day disposal period. An LPN confirmed during an interview that the open insulins should have been dated and disposed of within 30 days. The facility's policy, as provided by the Director of Nursing, requires that opened medications be dated and discarded according to manufacturer guidelines, typically within 28 days unless specified otherwise.
Privacy Concerns in Shared Bathroom
Penalty
Summary
The facility failed to ensure privacy for a resident, identified as Resident 57, in a shared bathroom setting. Resident 57 expressed concerns about privacy due to sharing a bathroom with two male residents from the adjacent room. Although she no longer used the toilet due to her continence status, she felt uncomfortable using the bathroom for washing her hands or face, fearing that a male resident might enter. The shared bathroom had doors leading to both her room and the neighboring room occupied by the male residents. Despite being cognitively intact, as indicated by a Significant Change Minimum Data Set assessment, Resident 57 had not previously voiced these concerns to the facility staff. The Director of Nursing acknowledged the situation but noted that the resident had not reported any privacy issues before and was currently out for dialysis.
Failure to Update Care Plans for Residents with Changing Medical Conditions
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect changes in the medical conditions of two residents. Resident 69, who had a history of MRSA infection, was observed without any signs of transmission-based precautions or personal protective equipment in his room, despite his care plan indicating a need for contact isolation due to an active MRSA infection. The resident's MRSA infection had resolved, and the care plan had not been updated to reflect this change, as confirmed by the wound nurse. Resident 57, who was receiving hemodialysis, had a care plan that inaccurately documented her dialysis access as a right chest permacath, while she actually had a right upper arm graft. This discrepancy was confirmed during an interview with the resident and later verified by the Director of Nursing, who contacted the dialysis center. The care plan had not been updated to reflect the current dialysis access site.
Failure to Monitor Edema and Document Medication Administration
Penalty
Summary
The facility failed to adequately monitor and treat a resident with edema, as well as ensure proper documentation and administration of medications for other residents. Resident 18, who has diagnoses including diabetes mellitus, heart disease, and chronic obstructive pulmonary disease, was observed with swollen legs and reported the condition to the nursing staff. Despite the resident's complaints and the presence of edema noted in a Daily Shift Report, there was no documentation in the progress notes or evidence that the physician had been notified. The resident's care plan included interventions for edema, but these were not documented as being followed. Additionally, the facility did not ensure that medications were administered and documented as scheduled for two other residents. Resident 91, who has Alzheimer's dementia and chronic pain, had multiple instances where opioid medication was not signed out as given or refused, with the DON suggesting the schedule should be revisited. Resident 120, with type 2 diabetes mellitus and dementia, had missing documentation for blood sugar checks and insulin administration, although the DON claimed these were performed. The lack of documentation and adherence to medication schedules indicates a failure in the facility's medication administration process.
Failure to Properly Flush PICC Line Before Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous fluids through a PICC line for a resident. During a medication pass, the Infection Preventionist (IP) was observed preparing and administering an antibiotic, meropenem, for a resident. The IP followed proper hand hygiene and used clean gloves, but did not flush the PICC line with the required 10 cc of normal saline before administering the antibiotic. Instead, she only injected 6 cc of normal saline, which was not in accordance with the physician's order or the facility's policy. The resident's medical record indicated a physician's order to flush the PICC line with 10 cc of normal saline before and after antibiotic administration to maintain patency every 8 hours. The facility's policy also required a 10 ml flush of normal saline for PICC lines before and after IV medication administration. During an interview, the IP acknowledged the error, indicating she should have flushed with the full 10 cc of normal saline prior to administering the antibiotics.
Failure to Provide Correct Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 70, who was observed with an incorrect oxygen flow rate and an unchanged humidity bottle. On two separate occasions, the resident was seen with a nasal cannula attached to a portable oxygen tank set at 4 liters per minute (lpm), despite a physician's order specifying a continuous oxygen flow rate of 2 lpm. Additionally, the water bottle on the oxygen concentrator was dated 7/29/24, indicating it had not been changed weekly as required by another physician's order. The resident's medical history included Parkinson's disease and chronic obstructive pulmonary disease, and the resident required substantial assistance for mobility and transfers due to moderate cognitive impairment. The facility's failure to adhere to the prescribed oxygen flow rate and maintenance schedule for the humidity bottle was confirmed during an observation and interview with the Cottage Unit Manager.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving hemodialysis by not adequately monitoring the dialysis access site. The resident, who was cognitively intact, had a right upper arm graft for dialysis access and an old, non-functioning right arm fistula. The care plan required assessment of the dialysis access site every shift for signs of complications such as excessive bleeding, drainage, swelling, redness, warmth, and to check for bruit and thrill. However, the Physician's Order Summary did not specify the location for monitoring bruit and thrill, nor did it include orders for monitoring other potential complications at the access site. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the resident lacked documentation of monitoring the right arm graft site for the specified complications. Although Dialysis Appointment Assessments were completed on dialysis days, they did not cover the required monitoring on non-dialysis days. The Director of Nursing acknowledged the need to clarify orders to include specific monitoring instructions for the dialysis access site. The facility's policy on Dialysis Care recommended keeping dialysis residents on hot charting to monitor for complications, but this was not adequately implemented for the resident in question.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) during medication administration. During an observation, the Infection Preventionist (IP) was seen preparing and administering intravenous medication to a resident without any signage or personal protective equipment bins indicating EBP in or around the resident's room. The IP prepared the medication, washed her hands, and donned clean gloves but did not change gloves or perform hand hygiene after reaching into her pocket during the procedure. The resident's records did not contain any physician's orders for EBP, despite the presence of a central line. The Director of Nursing confirmed that the resident should have been placed in EBP and that the IP should have changed gloves and performed hand hygiene after reaching into her pockets. The facility's policy on standard and transmission-based precautions indicated that EBP should be used for residents with indwelling medical devices, such as a central line, and that hand hygiene should be performed before and after contact with the resident and their environment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Valparaiso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Valparaiso | 1 mi | — | 15 | 0 |
| Life Care Center Of The Willows | 1 mi | — | 40 | 0 |
| Avalon Springs Health Campus | 1.4 mi | — | 14 | 0 |
| Brickyard Healthcare - Valparaiso Care Center | 2.2 mi | — | 0 | 0 |
| Ignite Medical Resort Chesterton | 6.2 mi | — | 27 | 0 |
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