Valley View Manor: Hospice Care Coordination Failures - MN
A complaint inspection completed November 19, 2025 cited the facility for failing to properly coordinate hospice services for residents in its care. The deficiency, tagged F0849, was classified as having minimal harm or potential for actual harm and affected a small number of residents.
What inspectors documented was a breakdown in the paperwork infrastructure that governs end-of-life care. The facility had not ensured it held the most recent hospice plans of care specific to each resident receiving those services. It lacked hospice election forms, which are the documents a resident or their family signs to formally choose comfort-focused care over curative treatment. Physician certifications and recertifications confirming each resident's terminal illness were missing or not properly maintained. So were the names and contact information for the hospice personnel involved in each resident's care.
That last gap matters in ways that are easy to underestimate. Hospice agencies are required to staff a 24-hour on-call system precisely because dying is not predictable. A resident's breathing changes at 2 a.m. Pain breaks through at a level the evening nurse has not seen before. The on-call number is how nursing home staff reach someone who knows that resident's hospice plan and can authorize a medication adjustment or talk a family member through what is happening. Valley View Manor had not ensured its staff had reliable access to that system.
The facility also lacked hospice-specific medication information for individual residents and hospice physician orders tailored to each person's condition. Hospice care is not generic. The medication regimen for a resident dying of end-stage heart failure differs from one dying of cancer or dementia. Orders written for one person's final weeks are not interchangeable with another's.
Beyond the documentation failures, inspectors found the facility had not properly oriented hospice staff to the facility's own policies and procedures. When outside hospice workers come into a nursing home to provide care, they are expected to understand the facility's systems, resident rights protocols, and record-keeping requirements. That orientation is the facility's responsibility. It had not been completed.
The coordinated care plans inspectors reviewed did not incorporate the most recent hospice plans of care alongside the services the facility itself was providing. A coordinated care plan, when it works, is a single document that shows exactly who is responsible for what, which nurse from which agency handles wound care, which aide assists with bathing, which hospice social worker is scheduled for family contact, and what the attending physician has most recently ordered. Without that document reflecting current hospice guidance, staff at Valley View Manor were working from an incomplete picture of what each dying resident needed.
The facility is a small operation in a rural corner of southwestern Minnesota, about 130 miles southwest of Minneapolis. Lamberton is a town of roughly 700 people. For families in that region, Valley View Manor may be the only realistic option for a loved one who needs skilled nursing care while on hospice.
CMS assigned the deficiency its second-lowest harm level, meaning inspectors did not find evidence that residents had been injured as a result of the documentation failures. But the classification also acknowledges that harm was possible. A missed medication order, an unreachable on-call nurse, a care plan that no longer reflects what the hospice team has prescribed: these are the conditions under which a person's final days become harder than they need to be.
The facility's plan of correction was not included in the inspection materials. For information on how Valley View Manor intends to address the deficiency, CMS directs the public to contact the facility or the Minnesota state survey agency directly.
Somewhere in that 200-bed building on East Ninth Avenue, residents are spending their last weeks. Their families are making decisions based on the assumption that the people caring for their loved ones have the right orders, the right numbers to call, and the right plan in front of them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Manor Hcc from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
Valley View Manor Hcc in LAMBERTON, MN was cited for violations during a health inspection on November 19, 2025.
A complaint inspection completed November 19, 2025 cited the facility for failing to properly coordinate hospice services for residents in its care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.