Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley View Healthcare & Rehab during CMS and state inspections, most recent first.
A resident with multiple diagnoses experienced a sudden change in mental and physical status, including difficulty following directions and increased need for assistance. Despite these changes, the nursing staff failed to perform a comprehensive assessment or notify the physician, leading to Immediate Jeopardy. The resident was later found deceased, with no documented assessments or vital signs taken during the shift.
The facility's call light system was inadequate, affecting all 33 residents. Staff were not provided with functioning devices to alert them of call light activations, and the system's design made it difficult to hear or see alerts unless in specific areas. The facility had a wireless system with pagers, but these were not in use, and the system did not integrate with staff communication devices.
A facility failed to implement a BIPAP order for a resident with obstructive sleep apnea, as the order was not transcribed into the electronic health record, and the resident did not receive the therapy. Interviews revealed that the family was not contacted to provide the device, and the physician was not notified of the lack of BIPAP availability. The facility's policy requires physician orders and informed consent, which were not adequately addressed.
Failure to Assess and Notify Physician for Resident's Change in Condition
Penalty
Summary
The facility failed to complete a comprehensive assessment, monitor, and notify the physician for a sudden change in mental and physical status for a resident who had a change in condition. The resident, who had diagnoses of type 2 diabetes, obstructive sleep apnea, weakness, and falls, demonstrated changes in mental status, speech, and mobility. Despite these changes, the licensed nursing staff did not comprehensively assess, monitor, or notify the physician, leading to a deficiency identified as past non-compliance and issued at Immediate Jeopardy. On the day of the incident, the resident was reported to have been perfectly fine earlier in the day, able to move independently with minimal assistance. However, later in the day, the resident exhibited significant changes, including difficulty following directions, increased need for assistance, and inability to articulate speech. Despite these observations by various staff members, including a physical therapist assistant and an occupational therapy assistant, the registered nurse on duty did not perform a comprehensive assessment or take vital signs, relying instead on the resident's self-reports. The situation escalated when the resident was found on the floor, unable to stand, and exhibiting signs of distress such as shaking and anxiety. The registered nurse called an ambulance but dismissed it without evaluating the resident. The resident was later found deceased in her room, with no comprehensive assessments or vital signs documented throughout the shift. The facility's policy required detailed observations and physician notification for significant changes in a resident's condition, which were not followed in this case.
Removal Plan
- Immediately sent RN-C home pending further investigation then was terminated from employment.
- Educare on change of condition assessment for all nurses with competency.
- Change of condition education is assigned for completion.
- All licensed staff were given written communication on change of condition-notification to the provider.
- Education on death policy.
- Interviews conducted with licensed and unlicensed staff confirmed competency of the facility process.
Deficient Call Light System in Facility
Penalty
Summary
The facility failed to ensure a complete and functional wireless call light system, which had the potential to affect all 33 residents. The system was inadequate as staff were not provided with functioning devices to alert them of call light activations. Observations and interviews revealed that the call lights could not be heard unless staff were in the hallway looking at a thin display bar. The system used a scroll board that only made a single high-pitched beep and did not indicate how long a call light had been activated. Additionally, the call system was separated by wings, and the transitional care unit suites lacked a scroll board, making it difficult for staff to be aware of call light activations. The Director of Nursing (DON) acknowledged that residents in the transitional care suites might experience delays in call light responses and advised them to activate their call lights preemptively. The facility had a wireless call light system with pagers, but these were not in use, and the call system did not integrate with the walkie-talkies used by staff. The call system employee confirmed that the facility had not ordered pagers since late 2022, and staff needed a functioning device to carry while working. The facility's policy stated that residents should have a means to call staff directly, but this was not effectively implemented.
Failure to Implement BIPAP Order for Resident
Penalty
Summary
The facility failed to process and implement a BIPAP order for a resident diagnosed with congestive heart failure, atherosclerotic heart disease, and obstructive sleep apnea. The resident's face sheet and outside physician orders indicated the need for BIPAP therapy upon admission. However, the facility's electronic health record did not reflect the transcription of this order, and the treatment administration records showed no evidence of the resident receiving BIPAP therapy during the specified dates. Additionally, the baseline care plan did not mention the requirement for BIPAP therapy or the condition it was prescribed for. Interviews with facility staff revealed a lack of communication and action regarding the BIPAP order. A licensed practical nurse stated that if the resident had an order, it would have been recorded in the treatment administration record, and the family would need to provide the device. The director of nursing acknowledged awareness of the BIPAP order but admitted that the physician was not notified, and the family was not contacted to bring the device. The resident's physician noted that without BIPAP, the resident could experience symptoms like snoring, gasping for air, and daytime sleepiness. The facility's policy on BIPAP use requires physician orders and informed consent, which were not adequately addressed in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd Lutheran Home | 10 mi | ★★★★★ | 2 | 0 |
| La Crescent Health Services | 13.3 mi | ★★★★★ | 25 | 1 |
| Tweeten Lutheran Health Care Center | 14.4 mi | ★★★★★ | 22 | 0 |
| Riverside | 15.9 mi | ★★★★★ | 12 | 0 |
| Benedictine Manor Of Lacrosse | 16.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.