Valley View Manor: Neglect Report Failures - MN
The resident, identified in inspection records only as R5, had been admitted to the Lamberton nursing home while under hospice care for ovarian cancer and thyroid cancer. She was cognitively intact — she understood what was happening to her and could say so. When the hospice registered nurse arrived for a routine visit that Thursday, R5 told her she had been sitting in her own feces for a long time, that staff would not help her change her brief or clean her up, and that she had not received a single shower since being admitted to the facility.
The nurse looked at R5's right lower leg and saw a large open blister and a large purple discoloration spreading across the back of the leg. It appeared to her to be a massive bruise. Nobody on staff could explain how it got there.
The hospice nurse asked the interim assistant director of nursing whether he knew anything about the wound or the bruise. He said he did not. She wanted to report what she had found to the director of nursing or the administrator. The director of nursing was busy with another resident at that moment.
So the hospice nurse said nothing and left.
Federal inspectors arrived at Valley View Manor on November 19, 2025, responding to a complaint. What they found was not just a woman who had been left in filth with an unexplained open wound. They found a facility where the systems meant to catch exactly this kind of situation had quietly collapsed, and where the people responsible for making those systems work were largely unaware they had.
The administrator, interviewed the day inspectors arrived, told them that hospice staff were considered contracted staff and were required to follow the same reporting policies as facility employees. If any staff member became aware of an allegation of neglect, the administrator said, they would report it immediately to the director of nursing or the administrator. The administrator had received no such report. Not from the hospice nurse. Not from anyone.
The facility's own Hospice Services Agreement, signed in February 2024, was explicit: hospice staff who became aware of any alleged violation involving mistreatment, neglect, or injury of unknown origin were required to report it to the facility administrator within 24 hours. The agreement covered exactly the kind of situation the hospice nurse had walked into, and walked away from, on November 13.
Two days after the inspection began, on November 21, inspectors interviewed the clinical director of the hospice agency. She said she was unaware whether her agency followed the facility's reporting policy. She was unaware whether her staff had ever received that policy. She was unaware that the hospice services agreement her agency had signed required immediate reporting to the facility administrator when an allegation came to light.
The agreement had been in place for nearly two years.
The inspection deficiency — cited under federal tag F0609, which governs timely reporting of suspected abuse and neglect — was rated at a level of minimal harm or potential for actual harm, the lowest tier on the scale. That rating reflects the regulatory framework's assessment of the reporting failure itself, not of what was done, or not done, to R5.
What happened to R5 after the hospice nurse's visit on November 13 is not detailed in the inspection record. Whether she continued to sit in soiled briefs, whether anyone investigated the blister and the bruise, whether the injury of unknown origin was ever reported to state authorities — none of that is answered in the documents inspectors produced.
What the record does show is that a woman with terminal cancer, who was cognitively intact and could articulate exactly what was being done to her and what was being withheld from her, told a healthcare professional she had been left in feces, that staff refused to clean her, and that she had gone without a shower since arriving at the facility. The healthcare professional who heard all of this had signed on, through her agency's own agreement, to report it. She saw an open wound and a bruise that had no explanation. She asked one person about it, got no answer, and decided not to pursue it further because the director of nursing appeared to be occupied.
R5's care plan, written on October 31, 2025, had already flagged her as a patient at high risk for skin breakdown because of her morbid obesity and limited mobility. The facility knew she was vulnerable. The hospice nurse knew it too. The open blister on her lower leg was the kind of wound that a care plan like hers was written to prevent.
The facility's own abuse and neglect reporting policy, though undated, required that any suspicion of neglect or injury of unknown source be reported immediately to the administrator, the director of nursing, and state officials. The hospice services agreement required the same. The administrator believed those requirements were understood and followed. The hospice clinical director did not know they existed.
The gap between what the paperwork required and what the people responsible for carrying it out understood is where R5's situation disappeared. She told someone. That someone had a legal and contractual obligation to act. The DON was busy. And so R5's account of sitting in feces, her unshowered weeks in the facility, the blister and the purple bruise on her leg — all of it went unreported to the administrator, unreported to the state, and undocumented as an allegation of neglect until federal inspectors showed up six days later following a complaint from someone else.
By then, R5 was still a patient at Valley View Manor. She was still dying of cancer. Whether anyone had cleaned her up, treated her wound, or explained the bruise is not something the inspection record addresses.
She had told someone. It just hadn't counted.
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 20, 2026 · Our methodology
Valley View Manor Hcc in LAMBERTON, MN was cited for neglect violations during a health inspection on November 19, 2025.
She was cognitively intact — she understood what was happening to her and could say so.
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.