Valley View Manor: Care Plan Failures Put Residents at Risk - MN
When inspectors visited the facility on November 18, 2025, they found the woman, identified in inspection records as Resident 6, lying in bed on top of the specialty mattress. She told inspectors she had been on it for some time because of a sore on her bottom and because she spends a lot of time in bed. A nursing assistant confirmed the same thing. The air mattress was real. The wound was real. The care plan said nothing about either.
The director of nursing told inspectors directly: R6's care plan had not been revised to include the air mattress, and it should have been revised as soon as it was placed on her bed.
Resident 6 had been living with left-side paralysis, diabetes, and heart failure. Her most recent assessment identified her as dependent for bed mobility and transfers, and at risk for developing pressure ulcers. Her existing skin care plan, last revised in April 2025, laid out interventions for protecting her skin, including a pressure-relieving cushion in her wheelchair and a standard pressure-relieving mattress in bed. It said nothing about an air mattress. It said nothing about a wound.
A nurse practitioner had noted in a rounding form dated November 10 that someone should check whether R6's air mattress was working. Eight days later, inspectors found the mattress in place and the care plan untouched.
The second resident caught in the same gap was identified as Resident 2, who had experienced a fall. After the fall, staff changed R2's transfer status and added a wheelchair, two concrete shifts in how the resident was supposed to be moved and supported. Neither change was reflected in R2's care plan. No updated fall prevention interventions were added. The transfer status still listed R2 as independent. The wheelchair did not appear.
A registered nurse told inspectors she was not aware that a care plan needed to be revised to reflect the new interventions. She believed that was the director of nursing's responsibility, not hers.
The interim assistant director of nursing, interviewed on November 12, confirmed that R2's care plan had not been updated to include any of the new fall prevention measures, and said that care plan revisions were the director of nursing's job, not the nurses'.
That answer, offered twice by two different staff members, points to something more than a paperwork gap. When the responsibility for keeping a resident's care plan current belongs entirely to one person, and that person doesn't update it, the plan stops reflecting the resident. Staff making decisions about how to move R2, or how to protect R6's skin, would be working from documents that no longer described the people in front of them.
The facility's own care plan policy, though undated, states that the interdisciplinary team is responsible for updating care plans when there has been a significant change in a resident's condition, when a desired outcome is not being met, and at least quarterly. A fall serious enough to prompt a transfer status change and the introduction of a wheelchair is a significant change. A wound serious enough to require an air mattress is a significant change.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a few residents. The inspection was conducted in response to a complaint.
For Resident 6, the air mattress was doing its job. Whether that would have remained true, with staff relying on a care plan that didn't mention the wound or the equipment managing it, is a question the updated document would have been meant to answer.
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.
She told inspectors she had been on it for some time because of a sore on her bottom and because she spends a lot of time in bed.
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.