Winona Lake, IN

Grace Village Health Care Facility

5-star overall rating with 5-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle

337 Grace Village Dr, Winona Lake, IN

(574) 372-6100

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1997-08-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.89

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

3.86

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

5.58

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

5.04

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.53

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.98

CMS adjusted RN staffing hours

Adjusted total hours

6.14

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

57%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,195

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.53

Composite VBP score used to determine payment impact.

Payment multiplier

0.9846

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.41

Baseline 18.84% · Performance 20.78% · Measure score 1.41 · Achievement 1.41 · Improvement 0

Healthcare-associated infections

Baseline 9.13% · Performance 8.95% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.52

Baseline 49.15% · Performance 49.28% · Measure score 3.52 · Achievement 3.52 · Improvement 0

Adjusted total nurse staffing

6.07

Baseline 3.52 hours · Performance 4.81 hours · Measure score 6.07 · Achievement 6.07 · Improvement 5.19

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.39%	10.72% 2.7 pts worse	No Different than the National Rate · Eligible stays 90 · Observed rate 16.67% · Lower 95% interval 8.65%
Discharge to community	45.01%	50.57% 5.6 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 43.04% · Lower 95% interval 36.37%
Medicare spending per beneficiary	0.86	1.02 0.2 pts better
Drug regimen review with follow-up	97.83%	95.27% 2.6 pts better	Numerator 45 · Denominator 46
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 46
Discharge self-care score	77.27%	53.69% 23.6 pts better	Numerator 34 · Denominator 44
Discharge mobility score	68.18%	50.94% 17.2 pts better	Numerator 30 · Denominator 44
Pressure ulcers or injuries, new or worsened	2.17%	2.29% 0.1 pts better	Numerator 1 · Denominator 46 · Adjusted rate 2.99%
Healthcare-associated infections requiring hospitalization	8.95%	7.12% 1.8 pts worse	No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 5.05%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 116
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	72.73%	56.45% 16.3 pts better	Numerator 32 · Denominator 44
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 31 · Denominator 31
Resident COVID-19 vaccinations up to date	30.43%	25.2% 5.2 pts better	Numerator 7 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	93.6% 5.3 pts better	93.4% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.0%	95.4% 2.6 pts better	95.5% 2.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.4%	3.8% 0.6 pts worse	3.3% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.5% · Q3 2.3% · Q4 6.8% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	24.6% 24 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	5.1%	5.6% 0.5 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 12.5% · Q3 0.0% · Q4 5.1% · 4Q avg 5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.1%	23.5% 8.4 pts better	19.6% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 17.1% · Q3 10.5% · Q4 12.8% · 4Q avg 15.1%
Percentage of long-stay residents who received an antipsychotic medication	7.4%	14.8% 7.4 pts better	16.7% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 5.9% · Q3 3.0% · Q4 8.1% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.4%	13.3% 10.1 pts worse	16.3% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 34.2% · Q3 10.1% · Q4 19.8% · 4Q avg 23.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.2%	11.7% 11.5 pts worse	14.9% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 40.0% · Q3 10.8% · Q4 18.4% · 4Q avg 23.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	5.6%	1.2% 4.4 pts worse	1.7% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.9% · Q3 2.3% · Q4 2.3% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.2%	24.2% 1 pts worse	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 25.9% · Q3 25.5% · Q4 26.4% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	0.6%	4.1% 3.5 pts better	5.1% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	81.6% 15.4 pts better	81.7% 15.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 95.7% · Q3 97.4% · Q4 98.4% · 4Q avg 97.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.9%	10.5% 5.4 pts worse	12.0% 3.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.5% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.7%	79.0% 6.7 pts better	79.7% 6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	40.9%	22.4% 18.5 pts worse	23.9% 17 pts worse	Short Stay · 20240701-20250630 · Adjusted 40.9% · Observed 36.2% · Expected 21.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-24 · Fire 2025-03-24

2 health deficiencies

Top issue: Infection Control (1 deficiency)

13 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-05-24 · Fire 2024-05-24

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

14 fire-safety deficiencies

Top issue: Miscellaneous (4 deficiencies)

Cycle 3 Health 2023-03-31 · Fire 2023-03-31

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

17 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-24

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-18

F · Potential for more than minimal harm 2025-03-24

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-18

E · Potential for more than minimal harm 2025-03-24

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-05-18

E · Potential for more than minimal harm 2025-03-24

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2025-05-18

E · Potential for more than minimal harm 2025-03-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-05-18

E · Potential for more than minimal harm 2025-03-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-05-18

F · Potential for more than minimal harm 2024-05-24

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2024-07-13

F · Potential for more than minimal harm 2024-05-24

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2024-07-13

F · Potential for more than minimal harm 2024-05-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-13

F · Potential for more than minimal harm 2024-05-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-13

F · Potential for more than minimal harm 2024-05-24

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-07-13

F · Potential for more than minimal harm 2024-05-24

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2024-07-13

E · Potential for more than minimal harm 2024-05-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-13

C · Minimal harm 2024-05-24