Inspection Reports for Grand Valley Health & Rehab
621 GRAND VALLEY BOULEVARD, IN, 46151
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 16, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a generally compliant record with most complaint investigations resulting in no cited deficiencies. Deficiencies noted in prior surveys primarily involved emergency preparedness and fire safety issues, such as incomplete fire drills, fire alarm testing, and hazardous area enclosures, as well as some documentation and notification concerns related to resident transfers and respiratory care. Complaint investigations were mostly unsubstantiated or found no related deficiencies, with no fines or enforcement actions listed in the available reports. The facility appears to have addressed some earlier fire safety issues by the July 18, 2024 revisit, indicating some improvement in compliance over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
Jan 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450267.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00450267 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 16
Medicaid Census: 70
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Dec 30, 2024
Visit Reason
This visit was for the investigation of complaints IN00449617 and IN00449649.
Findings
No deficiencies related to the allegations in complaints IN00449617 and IN00449649 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00449617 and IN00449649 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 88
Medicare Census: 10
Medicaid Census: 71
Other Payor Census: 7
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436244.
Findings
No deficiencies related to the allegations in Complaint IN00436244 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00436244 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 4
Medicaid residents: 72
Other residents: 17
Inspection Report
Re-Inspection
Census: 95
Capacity: 100
Deficiencies: 0
Jul 18, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/11/24.
Findings
At this PSR, Grand Valley Health and Rehabilitation was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Routine
Census: 96
Capacity: 100
Deficiencies: 7
Jun 11, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid participation requirements, including emergency preparedness and fire safety standards.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, hazardous area enclosure, cooking equipment safety, fire alarm system testing, sprinkler system inspection, fire safety plan completeness, and fire drill scheduling. Deficiencies included failure to conduct required emergency preparedness exercises, improper enclosure of hazardous areas, cooktop not deactivated when not in use, incomplete fire alarm testing documentation, overdue sprinkler system internal inspection, incomplete fire safety plan, and fire drills not held on varied dates.
Severity Breakdown
SS=F: 5
SS=E: 2
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to conduct at least two emergency preparedness exercises per year including unannounced staff drills. | SS=F |
| Hazardous area (Human Resource's Office) not enclosed with 1-hour fire rated barrier due to sliding glass windows with gaps. | SS=E |
| Cooktop in Physical Therapy area not deactivated when not in use and lacked a disconnect switch. | SS=E |
| Failed to ensure annual testing of all fire alarm system devices including pull stations and did not clarify visual and functional testing in reports. | SS=F |
| Failed to perform required 5-year internal inspection of sprinkler piping system; last documented inspection was over 5 years ago. | SS=F |
| Fire safety plan did not identify smoke barrier locations and incorrectly referenced battery powered smoke detectors which the facility does not have. | SS=F |
| Fire drills were not held on varied dates for all shifts and quarters; 11 of 12 drills were conducted during the last three days of each month. | SS=C |
Report Facts
Certified beds: 100
Census: 96
Plastic totes: 14
Fire drills: 12
Fire drills on last 3 days of month: 11
Smoke detectors: 111
Pull stations: 9
Inspection Report
Annual Inspection
Census: 90
Capacity: 90
Deficiencies: 0
May 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00433755.
Findings
Grand Valley Health & Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey and the Investigation of Complaint IN00433755. No deficiencies related to the complaint allegations were cited.
Complaint Details
Complaint IN00433755 was investigated and no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 90
Total census: 90
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420093 and IN00420624.
Findings
No deficiencies related to the allegations in complaints IN00420093 and IN00420624 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00420093 and IN00420624 found no deficiencies related to the allegations.
Report Facts
Census: 95
Total Capacity: 95
Medicare Census: 12
Medicaid Census: 72
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Jul 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407867 and IN00408791.
Findings
No deficiencies related to the allegations in complaints IN00407867 and IN00408791 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00407867 and IN00408791 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 88
Census total residents: 88
Census Medicare residents: 12
Census Medicaid residents: 66
Census other payor residents: 10
Inspection Report
Life Safety
Census: 90
Capacity: 100
Deficiencies: 1
May 15, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/15/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to penetrations in smoke barrier walls that were not properly fire caulked, potentially affecting 34 residents and 5 staff.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Penetrations caused by piping through 2 of 5 smoke barrier walls were not properly fire caulked, leaving half inch openings that could allow passage of smoke. | SS=E |
Report Facts
Certified beds: 100
Census: 90
Residents potentially affected: 34
Staff potentially affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chelsea Frederick | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Maintenance Director | Interviewed and confirmed the smoke barrier penetrations were not properly fire caulked | |
| Administrator | Participated in exit conference reviewing the findings |
Inspection Report
Life Safety
Deficiencies: 0
May 15, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 05/15/23 was completed on 06/22/23.
Findings
Grandview Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Census: 100
Capacity: 100
Deficiencies: 3
Apr 28, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 23 to April 28, 2023.
Findings
The facility was found deficient in ensuring proper written notification before transfer or discharge for one resident, notification of bed-hold policy for one resident transferred to hospital, and labeling and dating of oxygen tubing for five residents receiving respiratory care.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure written notification of transfer or discharge was given to resident or representative for 1 of 4 residents reviewed (Resident 57). | SS=D |
| Failed to ensure notification of bed-hold policy was provided for 1 of 4 residents reviewed for hospitalization (Resident 57). | SS=D |
| Failed to ensure oxygen tubing was labeled and dated for 5 of 5 residents reviewed for respiratory care (Residents 6, 47, 60, 51, and 44). | SS=E |
Report Facts
Census: 100
Total Capacity: 100
Medicare Census: 16
Medicaid Census: 74
Other Payor Census: 10
Survey Dates: 2023-04-23 to 2023-04-28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gustus | MSN, RN Consultant | Signed the report and provided facility policy information |
| Director of Nursing | Director of Nursing | Interviewed regarding deficiencies related to transfer notification and bed-hold policy |
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 28, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on April 28, 2023.
Findings
Grand Valley Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 0
Feb 22, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398047 and IN00398168.
Findings
Complaint IN00398047 was unsubstantiated due to lack of evidence. Complaint IN00398168 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398047 was unsubstantiated due to lack of evidence. Complaint IN00398168 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 94
Total Census: 94
Medicare Census: 11
Medicaid Census: 71
Other Payor Census: 12
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 0
Oct 24, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00387123 and IN00390036.
Findings
Both complaints were found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00387123 and Complaint IN00390036 were both unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 100
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 77
Census Payor Type - Other: 7
Inspection Report
Renewal
Deficiencies: 0
Aug 5, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 5, 2022.
Findings
Grand Valley Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure.
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