Cycle 1
Health 2025-06-12 · Fire 2025-06-12
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Martinsville, IN
Grand Valley Health & Rehab
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
621 Grand Valley Boulevard, Martinsville, IN
(765) 342-7114
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
91
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Hcf Management Indiana
Operator or chain grouping
Approved since
1996-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars
Changed ownership
No
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
0.48
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,878
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0007
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.65
Baseline 15.31% · Performance 18.35% · Measure score 6.65 · Achievement 6.65 · Improvement 0
Healthcare-associated infections
3.72
Baseline 4.71% · Performance 6.72% · Measure score 3.72 · Achievement 3.72 · Improvement 0
Total nurse turnover
7.60
Baseline 48.10% · Performance 32.61% · Measure score 7.60 · Achievement 7.60 · Improvement 6.16
Adjusted total nurse staffing
0.90
Baseline 2.37 hours · Performance 2.84 hours · Measure score 0.90 · Achievement 0 · Improvement 0.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 15.23% · Lower 95% interval 8.81% |
| Discharge to community | 60.35% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 106 · Observed rate 52.83% · Lower 95% interval 52.03% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 110 · Denominator 110 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 110 |
| Discharge self-care score | 74.03% |
53.69%
20.3 pts better
|
Numerator 57 · Denominator 77 |
| Discharge mobility score | 68.83% |
50.94%
17.9 pts better
|
Numerator 53 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 5 · Denominator 110 · Adjusted rate 3.89% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 6.58% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 4.69% |
42%
37.3 pts worse
|
Numerator 9 · Denominator 192 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 56 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 70 · Denominator 70 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.94% |
25.2%
14.3 pts worse
|
Numerator 7 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.5
1.4 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.4%
3.4 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.8%
1 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 2.5% · Q4 5.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.0% |
24.6%
48.4 pts worse
|
11.4%
61.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.5% · Q2 75.0% · Q3 71.2% · Q4 73.5% · 4Q avg 73.0% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.6%
4 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.5% · Q3 13.2% · Q4 12.7% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.8% |
23.5%
4.3 pts worse
|
19.6%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 32.4% · Q3 26.8% · Q4 26.1% · 4Q avg 27.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
14.8%
2 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.6% · Q3 14.8% · Q4 13.2% · 4Q avg 16.8% · 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 | 14.1% |
13.3%
0.8 pts worse
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 8.8% · Q3 11.6% · Q4 17.3% · 4Q avg 14.1% · 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 14.5% · Q2 32.8% · Q3 20.9% · Q4 25.0% · 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 | 4.6% |
1.2%
3.4 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 4.0% · Q3 7.8% · Q4 5.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
24.2%
0.7 pts better
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 22.6% · Q3 10.3% · Q4 25.9% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
4.1%
2.5 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.3% · Q3 8.5% · Q4 2.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
81.6%
15.2 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.8% · Q3 97.8% · Q4 94.6% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.0% |
10.5%
11.5 pts worse
|
12.0%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 23.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
79.0%
13.6 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.4%
1.8 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 30.4% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-13 · Fire 2024-05-13
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-28 · Fire 2023-04-28
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2025-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
F · Potential for more than minimal harm
2024-05-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-12
C · Minimal harm
2024-05-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-12
E · Potential for more than minimal harm
2023-04-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-07-11
E · Potential for more than minimal harm
2023-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-30
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Operational/Managerial Control · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Frederick, Chelsea
Operational/Managerial Control · Individual
Hafidh, Saad
Operational/Managerial Control · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Magnolia Health Management Xix LLC
Operational/Managerial Control · Organization
Reagan, Julie
Corporate Director · Individual
Reed, Stuart
Operational/Managerial Control · Individual
Sellers, Daniel
Operational/Managerial Control · Individual
Sellers, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Waters Of Martinsville, The
Martinsville, IN
1-star overall rating with 1-star inspections with $22,165 in total fines with 14 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
#2
Morgantown Woods Of Journey
Morgantown, IN
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Miller's Merry Manor
Mooresville, IN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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