Valparaiso Care & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Valparaiso Care & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 12, 2021

  Based on record review and interview, the facility failed to provide supervision to prevent an elopement of a cognitively and mentally impaired resident, who exited the facility unsupervised. The resident was last seen by an employee of the facility at 8:45 a.m. and exited out of the Main Dining Room door at 8:56 a.m. The facility was unaware the resident was not in the building for 4 1/4 hours. The Responsible Party/Power of Attorney was not notified for over 6 hours the resident had eloped and had not notified the local Police Department of the missing resident. The Responsible Party/Power of Attorney notified the local Police Department and the resident was located in a parking lot, 0.9 miles from the facility, for 1 of 5 residents reviewed for supervision. […]

• No harm, potential for more than minimal, patternF684Dec 17, 2025

  Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of assessment and monitoring of skin discolorations for 1 of 2 residents reviewed for non-pressure related skin conditions. The facility also failed to ensure residents received medications as ordered by the physician for 1 of 1 resident reviewed for dialysis, 1 of 2 residents reviewed for constipation/diarrhea, and 1 of 1 resident reviewed for insulin administration. (Residents 10, 8, 3, and 18)Findings include:1. On 12/11/25 at 3:19 p.m., Resident 10 was observed sitting on a couch in the lounge area. […]

• No harm, potential for more than minimal, patternF812Dec 17, 2025

  Based on observation and interview, the facility failed to ensure a clean and sanitary kitchen related to dirty shelves, carts and the walk in refrigerator in the main kitchen. This had the potential to affect the 109 residents who received meals prepared in the kitchen.Findings include:During the initial kitchen tour on 12/11/25 at 9:15 a.m. with the Kitchen Manager, the following was observed:a. In the walk-in refrigerator, there was a white powdery substance build up on the motor fan, and patches of whitish substance on the ceiling and walls. There was a musty odor present in the refrigerator.b. There were two carts near the door to the dining room that had crumbs, dried liquid and food substances spilled on the shelves.c. […]

• No harm, potential for more than minimal, patternF921Dec 17, 2025

  Based on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to accident hazards observed to the hallway on the dementia unit during construction, and dirty resident care equipment on both units. (Cottage, East Unit, [NAME] Unit) Findings include:1. On 12/11/25 at 10:30 a.m., the Cottage Dementia Unit was observed. There were multiple residents and staff observed in the dining area and lounge area. The hallway to the resident rooms had two fire doors closed. The door did not have windows to see into the hallway. Upon opening the door to the hallway, there was someone standing on a ladder. The door was then closed and staff were asked if people were able to go back there. […]

• No harm, potential for more than minimal, patternF761Aug 9, 2024

  Based on observation, record review, and interview, the facility failed to ensure medications were stored properly, with appropriate labeling and not expired, for 2 of 4 medication carts observed. (East Cart and Cottage Cart) Findings include: 1. On [DATE] at 1:28 p.m., the following was observed on the East Cart with LPN 1: - A Basaglar KwikPen (insulin) was dated with an open date on [DATE]. - A Rezvoglar KwikPen (insulin) was dated with an open date on [DATE]. - A Toujeo SoloStar (insulin) pen was opened with no open date written on the pen. - A Basaglar KwikPen was opened with no open date written on the pen. During an interview on [DATE] at 1:35 p.m., the East Unit Manager indicated the open insulins should have been dated and disposed of 30 days after opening. 2. […]