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Complaint Investigation

Grand Valley Health Care Center

April 30, 2026 · Van Nuys, CA · 13524 Sherman Way
Citations 2
CMS Rating 1/5
Beds 99
Provider ID 056363
Healthcare Facility
Grand Valley Health Care Center
Van Nuys, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

GRAND VALLEY HEALTH CARE CENTER in VAN NUYS, CA — inspection on April 30, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689
Quality of Life and Care Deficiencies

During a concurrent interview and record review on 4/29/2026 at 5:10 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's Fall Risk Evaluations dated 4/6/2026 and 4/9/2026 and stated that the DON completed the Fall Risk Evaluations after the fall incidents occurred.

The DON stated that the fall that occurred on 4/6/2026 was not reflected in the response to the history of falls section for the past three (3) months.

The DON further stated that the gait and balance items - decreased muscular coordination, change in gait pattern, or gait problems were not marked because the resident had been transferred to the hospital via paramedics (a highly trained healthcare professional who provides advanced emergency medical care, stabilization, and transportation for patients in crisis situations, usually outside of a hospital), and the DON was unable to personally assess the resident's gait and balance at that time.

The DON further stated that when completing Resident 1's Fall Risk Evaluation dated 4/9/2026, following the second fall, the DON obtained information from the rehabilitation therapy personnel that Resident 1 did not demonstrate issues related to decreased muscular coordination, change in gait pattern, or gait problems therefore, those items were not marked on the evaluation, and the DON left those items blank.

When the DON was asked about the purpose of accurately completing the Fall Risk Evaluations, the DON stated that the assessments should be completed correctly to establish the development of individualized, person-centered care plans and to reduce each resident's risk for falls.During a review of the facility's policy and procedures (P&P) titled, Fall Risk and Prevention of Injury to include Pathological Fracture (broken bone caused by disease) last reviewed on 8/28/2025, the P&P indicated, It is the policy of the facility to identify that are at risk for falls to implement a plan of care in an attempt to prevent falls.

Upon admission, a Fall Risk Assessment will be completed for all residents.

The Fall Risk Assessment will be reviewed quarterly and after each fall.

The incident report and the investigation will be reviewed by the Interdisciplinary Team (IDT - a group of different health professionals-such as doctors, nurses, therapists, and social worker who meet regularly to create a single, coordinated care plan for a resident) with recommendations for additional approaches to prevent further falls.

056363 04/30/2026

Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

that each resident is assessed for their hydration status on admission, within the assessment period,

on 8/28/2025, the P&P indicated, Residents will be screened on admission, quarterly, annually, and

no reliable calculation to determine a resident's fluid needs, an assessment should take into consideration characteristics pertinent to each resident, such as age, medical diagnoses, activity level, etc.

Residents identified with the potential for, or actual dehydration will be assessed for risk factors and appropriate recommendations shall be made.

These risk factors and interventions will be documented on the plan of care.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VAN NUYS, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAND VALLEY HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.