Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 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 assess and monitor a resident’s skin discolorations, even though bruising and other discolorations were observed on the hands and forearm and the wound nurse was unaware of them. The facility also missed multiple ordered doses for a resident on dialysis, a resident with diabetes receiving insulin, and a resident with cancer receiving several scheduled meds, including calcitriol, insulin, buspirone, lactulose, nebulizer treatments, oxycodone, and lidocaine. The DON stated calcitriol was available in the EDK and that staff had no further information about the missed meds.
Unsanitary Kitchen Conditions: Surveyors observed a dirty walk-in refrigerator with a white powdery buildup on the fan, whitish substance on the ceiling and walls, and a musty odor. Two carts near the dining room door and shelves below the counter also had crumbs, dried liquid, and food substances. The Dietary Mgr stated the shelves were cleaned weekly and that she had tried to remove the substance from the refrigerator but was unable to do so.
Inaccurate MDS assessments were completed for three residents. One resident with dementia had an MDS that failed to reflect ongoing antipsychotic use despite an active Risperdal order and MAR documentation. Another resident’s MDS incorrectly indicated a chair restraint was used even though no restraint was observed and no orders or assessments supported it. A third resident with a gastrostomy tube had an MDS that did not mark tube feeding despite the tube being in use and showing drainage at the insertion site.
Care plans were not updated for two residents. One resident had a suprapubic urinary catheter, but the care plan still reflected an indwelling catheter order and did not document the suprapubic catheter. Another resident was on EBP with a trach and G-tube, and although signage and PPE were in place, there was no care plan for EBP in the record.
A resident with L-sided hemiplegia, a contracted hand, and dependence for bed mobility, transfers, and toileting was observed without the ordered palm protector in place on multiple occasions. The care plan ordered daily passive ROM to the LUE, but restorative documentation showed very limited ROM provided and no refusals recorded, while the resident said he was not receiving restorative nursing services and wanted them.
Failure to document meal intake for a resident with dementia, dysphagia, and significant weight loss. The resident was identified as a nutritional risk with a care plan intervention to monitor food and fluid intake at meals, but multiple breakfast, lunch, and dinner entries were left undocumented over the review period. The DON stated staff should have documented the resident’s intake amounts or refusal.
Failure to Provide Ordered G-Tube Site Care: A resident with a g-tube and trach status reported bleeding at the insertion site for two months, and surveyors observed dark drainage and soiled or missing gauze at the site. The chart included an order to cleanse the site with soap and water, pat dry, and apply gauze every shift, along with care plan directions to monitor for infection and document findings, but the site was observed with buildup of dark discharge and no gauze in place.
Incomplete MAR documentation showed that a resident with HTN, ESRD, and obstructive uropathy who received dialysis had daily losartan and furosemide doses recorded as not given due to dialysis. The DON stated the meds were actually refused and should have been documented as refusals rather than as missed doses for dialysis.
The facility failed to follow infection control measures for three residents. A resident with an indwelling urinary catheter was observed with the drainage bag on the floor despite a care plan directing that no part of the drainage system touch the floor. During tracheostomy care for another resident, an RT did not use the sterile gloves from the kit and instead used gloves from his pocket. A third resident had a doorway sign for EBP and PPE nearby, but there were no EBP orders or care plans in the chart.
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.
Failure to Assess Skin Changes and Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that skin discolorations were assessed and monitored for Resident 10, who had diagnoses including atrial fibrillation, hypertension, and dementia and was cognitively impaired with partial moderate assistance needs for bed mobility, transfers, and walking. Purple discolorations were observed on the tops of both hands, and later additional scabbed areas and a discoloration on the left forearm were seen. A weekly skin assessment dated 12/15/25 indicated no skin alterations, including bruising, and the wound care nurse stated she was unaware of the discolorations and that they had not been assessed or monitored. The facility policy required direct care staff to report skin alterations, including bruises, to a licensed nurse for further assessment. The facility also failed to administer calcitriol as ordered for Resident 8, who had hypertension, end stage renal disease, and obstructive uropathy and received dialysis services. The physician ordered calcitriol 0.25 mcg daily for end stage renal disease, but the November 2025 MAR showed multiple missed administrations because the drug item was not available or was waiting on arrival. The DON stated the medication was in the emergency drug kit and staff could have obtained it from there while waiting for pharmacy delivery. For Resident 3, who had type 2 diabetes mellitus and severe cognitive impairment, the MAR showed several missed administrations of insulin lispro and insulin glargine despite physician orders for insulin lispro four times daily per sliding scale and insulin glargine 20 units daily. The care plan identified the resident as at risk for adverse effects of hyperglycemia or hypoglycemia and included interventions to provide medications as ordered and monitor blood sugars as ordered. The DON stated nurses ran EMAR compliance checks and reported no missed medications, but had no further information. For Resident 18, who had lung and bone cancer and was cognitively intact, the MAR showed missed administrations of buspirone, lactulose, ipratropium-albuterol nebulizer treatments, oxycodone, and lidocaine cream despite active physician orders for each medication, and the DON again had no further information to provide.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen when surveyors observed dirty shelves, carts, and a walk-in refrigerator in the main kitchen. During the kitchen tour, a white powdery substance was seen built up on the motor fan in the walk-in refrigerator, with patches of whitish substance on the ceiling and walls and a musty odor present. Two carts near the dining room door had crumbs, dried liquid, and food substances on the shelves, and the shelves below the counter also had crumbs, liquid spillage, and food substances. The Dietary Manager stated the shelves were cleaned weekly and that she had tried to remove the substance from the refrigerator walls and ceiling but was unable to do so. The Maintenance Director later stated he was unaware of the white substance in the walk-in refrigerator.
Inaccurate MDS Assessments for Medication, Restraint, and Tube Feeding
Penalty
Summary
The facility failed to ensure MDS assessments were accurately completed for three residents related to antipsychotic medication, restraints, and tube feeding. For Resident 59, who had diagnoses including dementia with behavioral disturbance, anxiety disorder, and type 2 diabetes mellitus, the Quarterly MDS dated 10/22/25 indicated no antipsychotic medication had been received since the prior assessment, even though the Physician's Order Summary listed Risperdal Consta 25 mg IM every 2 weeks and the MAR showed a Risperdal injection was given on 10/9/25. The MDS Coordinator later stated there was a data entry error regarding the antipsychotic medication. For Resident 11, who had diagnoses including dementia, type 2 diabetes mellitus, and generalized anxiety disorder, the Quarterly MDS dated 11/3/25 indicated a chair restraint to prevent rising was used less than daily. However, on observation the resident was sitting in a wheelchair with no restraint observed, and the record contained no Physician's Orders or assessments showing a chair restraint had been used. For Resident 79, who had diagnoses including gastrostomy and tracheostomy status, the Quarterly MDS dated 12/4/25 indicated the resident was cognitively intact and tube feeding was not marked, despite observation of a gastrostomy tube used for tube feedings with drainage and a soiled split gauze at the insertion site. The resident also stated the gastrostomy tube had been bleeding for the last two months, and the MDS Coordinator stated this was a data entry error.
Care plans not updated for suprapubic catheter and enhanced barrier precautions
Penalty
Summary
The facility failed to ensure that the care plan was updated for a resident with a suprapubic urinary catheter. Resident 2 had diagnoses including obstructive and reflux uropathy and acute and chronic respiratory failure, and the quarterly MDS indicated severe impairment for daily decision making and the presence of an indwelling urinary catheter. The record showed a physician order for a Foley catheter, while a progress note documented that the resident arrived at the facility with an 18 Fr, 30 mL suprapubic catheter draining clear yellow urine. During interview, the DON stated she was unsure when the suprapubic catheter had been placed and that the care plan would be updated to reflect the suprapubic catheter. The facility also failed to have a care plan for enhanced barrier precautions for Resident 79. She was observed sitting up in bed with a tracheostomy and gastrostomy tube, and a sign on the door indicated enhanced barrier precautions with PPE available nearby. The December 2025 physician order summary indicated the resident was in enhanced barrier precautions, but the record contained no care plan related to that status. During interview, the Infection Preventionist stated there should have been a care plan initiated for the resident being in enhanced barrier precautions.
Failure to Provide Ordered Splinting and Restorative ROM
Penalty
Summary
The facility failed to ensure a hand splinting device was in place as ordered and failed to provide restorative nursing care as ordered for a resident with left-sided hemiplegia, heart failure, and an unspecified mood disorder. The resident was cognitively intact, dependent for bed mobility, transfers, and toileting, and had a contracted left hand. On multiple observations, the resident was in bed without the ordered left-hand palm protector or carrot in place, despite a physician’s order for palm protectors to the left hand to be on in the morning and off in the evening. The resident’s care plan directed passive ROM to the left upper extremity 5 to 7 days a week, with 10 repetitions for 2 sets daily to address weakness and decrease contractures. However, the restorative nursing record showed ROM was provided only once in December and on several scattered days in November, with no refusals documented. The resident stated he was not receiving restorative nursing services but would like to, while the MDS nurse stated she was aware there were no refusals documented and indicated the resident refused frequently.
Failure to Document Meal Intake for Resident With Weight Loss
Penalty
Summary
The facility failed to monitor nutritional intake for meals for a resident with a history of weight loss. The resident had diagnoses including dementia, hypertension, anxiety, tremors, and dysphagia, and the admission MDS indicated severe cognitive impairment, required setup for eating, and had experienced a weight loss of 5% or more. The care plan identified the resident as a nutritional risk with significant weight loss and included an intervention to monitor food and fluid intake at meals. Record review showed the resident weighed 191.6 lbs on 11/11/25 and 179 lbs on 12/02/25, a 6.58% weight loss. Review of the Intake - Breakfast, Lunch, and Dinner documentation for the prior 30 days showed multiple meals with no documented consumption amounts, including several breakfasts, lunches, and dinners. During interview, the DON stated staff should have been documenting the resident's meal intake amounts or documenting when he refused.
Failure to Provide Ordered Care for G-Tube Site
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received care and services as ordered by the physician for treatment of the area around the insertion site. Resident 79, who had diagnoses including gastrostomy and tracheostomy status and was cognitively intact, reported that the g-tube had been bleeding for the last two months. On observation, the gastrostomy tube had a split gauze that was soiled with dark colored drainage from the insertion site. The resident’s record showed a physician’s order to cleanse the gastrostomy site with soap and water, pat dry, and apply gauze every shift. The care plan identified the resident as at risk for complications related to tube feeding and directed staff to cleanse around the site as ordered, observe and document symptoms of intolerance such as infection at the insertion site, pain at the site, and signs of infection such as redness, warmth, and malodorous drainage, and notify the physician. When the resident was later observed with the DON present, the insertion site had a buildup of dark colored discharge surrounding it and there was no gauze in place.
Incomplete Medication Administration Documentation for Resident on Dialysis
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records related to medication administration for one resident receiving dialysis. The resident had diagnoses including hypertension, end stage renal disease, and obstructive uropathy, and was cognitively intact per the admission MDS assessment dated 11/11/25. The resident received antidepressant, diuretic, and antiplatelet medications and dialysis services. The December 2025 Physician's Order Summary included orders for furosemide 40 mg daily, losartan 50 mg daily, and dialysis at a center on Monday, Wednesday, and Friday at 11:00 a.m. The November and December 2025 MARs showed that losartan was not administered on 11/7, 12/1, 12/3, and 12/8/25 and that furosemide was not administered on 12/8/25, with the MAR documenting the reason as dialysis. During interview, the DON stated the medications were not administered because the resident refused them and that staff should have documented refusal rather than dialysis.
Infection Control Failures With Catheter Care, Tracheostomy Care, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control measures were followed for a resident with an indwelling urinary catheter. Resident 62, who had diagnoses including metabolic encephalopathy, neuromuscular dysfunction of the bladder, and chronic pain, was observed in bed with the catheter bag lying on the floor on multiple occasions. The resident’s quarterly MDS indicated he was cognitively intact, dependent for toileting, needed partial assistance for bed mobility, and had an indwelling urinary catheter. The resident’s care plan directed staff not to allow tubing or any part of the drainage system to touch the floor, and the DON stated the resident was putting the catheter bag on the floor and was educated not to do so. The facility also failed to follow infection control practices during tracheostomy care and did not have orders or care plans for enhanced barrier precautions for another resident. During tracheostomy care for Resident 2, the RT removed and replaced gloves after the sterile gloves in the kit did not fit and then used gloves taken from his pocket to perform the procedure. The facility policy for tracheostomy care required aseptic technique, removal of gloves, hand hygiene, and aseptic placement of sterile gloves. In addition, Resident 141 had a sign posted at the doorway indicating enhanced barrier precautions and PPE available nearby, but the physician order summary contained only wound care orders and there were no orders or care plans for enhanced barrier precautions. The Infection Preventionist stated the resident was in enhanced barrier precautions due to wounds and that orders and a care plan should have been present.
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.
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.
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What surveyors actually found near you
We read the 648 citations issued within 25 miles in the last 12 months — including the 3 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 0 |
| Ignite Medical Resort Chesterton | 6.2 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.