Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley View Home during CMS and state inspections, most recent first.
Lack of Meaningful Activities in Memory Care Unit: Two residents in the memory care unit were observed without meaningful engagement, with one resident wandering between areas and another sleeping on a couch in the common area. Staff reported that regular activities were not being provided, the unit did not really use the activity calendar, the TV stayed on the same show for two days, and there was no specific calendar developed to meet the needs of the memory care population.
Failure to verify self-administration of medication. An LPN prepared acetaminophen for a resident, left the pills at bedside, and exited without observing ingestion. The resident's EHR did not show a self-administration assessment, care plan entry, or order for independent med administration, and the nurse stated the resident did not appear to have such an assessment.
A staff member failed to protect two vulnerable residents from abuse and neglect. One resident with impaired cognition and significant neurologic diagnoses was left unattended at an off-site dental appointment for over an hour and was later found choking on a supplement. Another resident was physically handled during ADL care when the staff member grabbed the resident by the hair, arm, and beard, pushed the resident against a wall, and pulled the resident's head forward, according to witness statements and the facility investigation.
Improper Storage of Food and Drinks in Kitchen: Boxes of supplemental drinks, Gatorade, and green beans were observed on the kitchen and dry storage floors, and one box of supplemental drinks was being used to prop open the kitchen door. An MDS/food service staff member stated the delivery had arrived late, the items had not been put away, and she knew food should not be stored on the floor.
The facility did not maintain a designated full-time DON for an extended period, leaving the position vacant while DON responsibilities were informally divided among the IDT. Emails from the administrator showed that the previous DON had left and that a job posting was created, but there was no documentation that the DON’s duties were specifically reassigned to an RN or multiple RNs during the vacancy. A later email documented the start date of a new DON, confirming a gap of several weeks without a formally designated DON.
A resident with dementia, a trauma history, hallucinations, and longstanding behavioral symptoms such as wandering into other rooms, verbal and physical aggression, and disrobing experienced two separate sexual incidents with male residents. In one event, a male was found in the resident’s room with his hands down her pants while she verbally rejected him; in another, staff found a male without pants lying on top of the fully clothed resident on his bed while she yelled for him to get off. Staff interviews and records showed that, although non-pharmacologic interventions (snacks, showers, one-on-one, aroma therapy, warm towels) and multiple psychotropic medication changes were used, the facility did not develop or document a defined monitoring and supervision program specifying the level, duration, or methods of oversight to address the resident’s wandering, entry into other rooms, and sexually related interactions after these incidents, nor were the sexual encounters incorporated as identified triggers in the care plan.
The facility failed to report a resident-to-resident abuse incident to the State Survey Agency within the required 24-hour timeframe. Staff reported that incidents must be reported within 24 hours, with 2-hour reporting for serious bodily injury and investigation results due within 5 days, and the facility’s written policy reflected these requirements. However, an altercation between two residents was reported more than 24 hours after it occurred, contrary to the facility’s mandatory reporting policy and the timelines described by staff.
The facility failed to screen visitors for COVID-19 symptoms during an outbreak, neglected to post transmission-based precaution signage for COVID-19 positive residents, and did not practice proper hand hygiene during a laundry pass. Additionally, enhanced barrier precautions were not followed for residents with indwelling medical devices, increasing the risk of infection spread.
The facility did not document declinations or provide education on the COVID-19 vaccine for two residents whose representatives refused the vaccine. Staff confirmed the absence of signed declinations and educational documentation, contrary to facility policy requiring such records in the medical file.
A resident at nutritional risk experienced a severe weight loss due to the facility's failure to implement care plan interventions. Observations showed the resident's meals were left untouched, and staff did not provide necessary encouragement or cueing during mealtimes. The resident's weight was not monitored weekly as required by facility policy, contributing to a 9.2% weight loss over three months.
The facility failed to label and date food items in the resident nourishment refrigerator, as observed with an unlabeled Tupperware containing an unknown substance. A staff member indicated that housekeeping was responsible for cleaning these refrigerators and noted that family members often placed items without staff knowledge. The facility's policy required all prepared food to be labeled, dated, and consumed within three days.
A facility failed to ensure a resident received the pneumococcal vaccine series. The resident's immunization record showed they received one vaccine in 2018, but the type was unspecified. Consent for further vaccination was given in 2024, but a staff member admitted to not arranging a vaccination clinic and being behind on immunization reviews. Facility policy required assessment for vaccine eligibility within five days of admission, which was not followed.
A cognitively impaired resident with a history of elopement attempts left a facility unsupervised, reaching a nearby school playground. The resident's care plan included interventions to prevent elopement, but several staff members were unaware of these measures. The facility's elopement book was not easily accessible, and communication about elopement risks was insufficient, contributing to the incident.
Lack of Meaningful Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide meaningful activities for residents in the memory care unit, including residents #43 and #44. During observation, resident #43 was seen sitting alone in the dining room, then wandering between his room, the hallway, and the common room, where he sat watching television before wandering back to his room. No activity was occurring at the time. Resident #44 was observed sleeping on the couch in the common area, and staff member G stated that she preferred to sleep on the couch throughout the day and night because she had a fear of sleeping in her room. When questioned, staff member G offered the resident a Dilly Bar and took her outside for fresh air after noting there were no activities occurring. Staff interviews showed that regular activities were not being provided in the memory unit. Staff member G stated the CNAs did not have regular activities and that they just let things happen naturally, despite the facility having a calendar that was not really used in the unit and not having a copy of the calendar available there. Staff member L stated the television had been on the same show for two days straight. Staff member B said there had been discussion about needing more activities, but it had not yet been addressed. NF3 stated resident #43 needed more activities, more time outside, more music, and more ambulation/exercise, and believed the resident was restless and that this contributed to more behaviors. Staff member E stated the memory unit activities included towel folding, tactile boards, church services if wanted, coloring supplies, and occasional nail painting, but there was no specific calendar developed to meet the needs of the memory unit population.
Failure to Verify Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the IDT verified that resident #4 was clinically appropriate to self-administer medications before medication was left for the resident to take independently without supervision. During an observation on 6/17/26 at 11:27 a.m., staff member K prepared two acetaminophen 500 mg tablets for resident #4, placed them in a pill cup on the bedside table, and left the room without observing the resident take the medication. During an interview immediately afterward, staff member K stated resident #4 did not appear to have a self-administration of medication assessment and acknowledged she did not think about it before leaving the medication without observing him take the pills. Review of resident #4's EHR did not show a self-administration assessment, a care plan entry for self-administration, or an order for self-administration of medications. The facility policy stated that if a resident requests to administer medications independently, a nursing team member will complete the Self-Administration of Medication Observation and the care plan and MAR will be updated to reflect the resident's self-administration capability.
Abuse, Neglect, and Unsafe Supervision of Two Residents
Penalty
Summary
The facility failed to protect two vulnerable residents from abuse, neglect, and psychosocial harm involving staff member P. One resident, with a BIMS of 10 and diagnoses of traumatic brain injury, quadriplegia, and major neurocognitive disorder, was left unattended at an out-of-town dental appointment for over an hour after staff member P dropped the resident off while the office was closed for lunch. The resident was found by concerned individuals in distress, coughing/choking on a supplemental drink, with the wheelchair locked and no one present to assist or supervise the resident. The facility documented the event as abuse, neglect, and use of restraint(s). The facility also verified an allegation of staff-to-resident abuse involving another resident during ADL care. Witness statements described staff member P holding the resident by the hair, arm, and beard, pushing the resident against a wall, and pulling the resident's head forward while the resident was being assisted after the toilet was found covered in feces. Staff members reported the resident had a history of aggression during care, and one witness stated the resident was not hitting, kicking, or yelling when staff member P used the physical interventions. The resident's family member stated she was upset by the incident and believed staff should have stepped back and reapproached the resident later rather than forcing care. The report also states staff member P had previously been educated on not leaving residents unattended at off-site appointments, yet later continued to disregard resident safety and care needs. Facility witness statements and the internal investigation verified the abuse allegation, and the resident's family member reported concern that the resident appeared fearful and upset after the incident. The facility's resident transportation and scheduling policy did not address leaving cognitively impaired residents unattended.
Improper Storage of Food and Drinks in Kitchen
Penalty
Summary
The facility failed to ensure boxes of resident food and drinks were stored off the floor in the kitchen area. During observations, one box of supplemental drinks was found on the kitchen floor upon entry, and later two cases of Gatorade, one case of green beans, and one case of supplemental drink were observed on the dry storage floor. At another observation, a box of supplemental drinks was found on the floor propping open the kitchen door. During interview, staff member M stated the food delivery truck had arrived late the previous day, she was aware the food had not been put away and was on the floor, and she was also aware the supplemental drink was being used to prop open the kitchen door. Staff member M stated this had been the practice since the door stopper went missing and acknowledged that boxes of food should not be stored on the floor.
Failure to Maintain a Designated Full-Time DON
Penalty
Summary
The facility failed to designate a full-time DON as required, leaving the position vacant for 37 days. During interviews, staff members B and C reported that the facility had been without a DON for a little over a month and that DON tasks were divided among the IDT during this period. An email from staff member A dated 9/8/25 showed an advertisement posting for the DON position and indicated that the IDT took over DON tasks after the previous DON left, but there was no documentation that the prior DON’s duties were specifically reassigned to an RN or multiple RNs. Another email from staff member A on 9/8/25 confirmed that the previous DON no longer worked at the facility, and a subsequent email dated 10/16/25 documented that staff member B started as the new DON on that date, confirming the facility was without a designated DON from 9/8/25 through 10/16/25. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of a designated full-time DON and the absence of documented reassignment of DON responsibilities to an RN during the vacancy period.
Failure to Implement Adequate Supervision and Monitoring After Resident Sexual Incidents
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement necessary and beneficial supervision and monitoring interventions for a cognitively impaired resident with a history of trauma and significant behavioral symptoms, including wandering into other residents’ rooms and sexually related interactions with male residents. Interviews with multiple staff members confirmed that the resident frequently wandered the halls, entered other residents’ rooms, displayed verbal and physical aggression, yelled, ran on the unit, and sometimes removed her clothing or kept her hands in her pants. Staff were aware that the resident had a trauma history, including being locked in her room by a family member prior to admission, and that she had auditory and visual hallucinations, paranoia, and worsening behaviors around menstruation. Despite this, the care plan and behavior documentation did not clearly link her behaviors to the sexual interactions with male residents or identify new contributing factors after those events. The record shows two separate sexual incidents involving the resident and male residents. In the first incident, documented in the nursing notes, a male resident was found in the resident’s room with his hands down the front of her pants while she stated, "I don't like you." The male was redirected, and the provider adjusted medications, but documentation only stated that staff were to monitor the resident for increasing behaviors without specifying how long, what level of monitoring, or how staff were to keep her safe. In the second incident, staff heard the resident yelling "help me" and "get off" and found her fully clothed, lying crossways on a bed in a male resident’s room, with the male resident on top of her without pants and making thrusting movements. Staff separated the residents and returned her to her room, and again documentation only referenced closer monitoring without defining duration, intensity, or specific safety measures. Behavior review notes from several months showed persistent and escalating behaviors: wandering, pacing, entering other residents’ rooms, refusing redirection, yelling, crying, verbal hallucinations, paranoia, refusing medications and care, physical and verbal aggression toward staff, slamming and banging on doors, furniture, and walls, and attempts to pull her pants down in common areas. After the sexual incidents, new behaviors such as having her hands in her pants and attempting to remove clothing in public areas appeared, along with increased agitation, refusal of meals and medications, and statements that people were trying to kill or be mean to her. The behavior review identified triggers such as incontinence, reportable events, shingles, dental pain, clothing preferences, and phone calls with family, and listed non-pharmacologic interventions like snacks, one-on-one time, walking with staff, back rubs, aroma therapy, warm towels, and use of different staff. However, the care plan and behavior documentation did not incorporate the sexual encounters as triggers, did not identify prior sexual abuse as a trauma factor, and did not specify any enhanced supervision or monitoring level to protect the resident from further harm related to her wandering and sexually related interactions. The care plan for cognitive loss/dementia and psychosocial well-being included general interventions such as providing consistent caregivers, encouraging expression of feelings, and assisting the resident to avoid trauma triggers, with trauma history listed as car accidents, fires, heart attacks, deaths in the family, and the murder of an aunt. There was no mention of sexual trauma or the recent sexual incidents as part of her trauma profile. Behavioral symptom interventions, many of which were not initiated until after the period of escalating behaviors, focused on pain assessment, use of different staff, aroma therapy, warm towels, and recognition that menstruation worsened behaviors. Medication reviews showed multiple antipsychotic and psychotropic adjustments, including Abilify, Seroquel at various doses, Haloperidol, and PRN Ativan, with documentation that Seroquel changes had little to no effect on her behaviors. Despite ongoing documentation of high-risk behaviors and two documented sexual encounters with male residents, the facility did not develop or document a clear, individualized monitoring and supervision program specifying the level, duration, and methods of oversight needed to maintain the resident’s safety in relation to her wandering and sexual encounters.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of suspected abuse within 24 hours as required by its policy and staff-stated procedures. During interviews, staff members B and C stated that incidents must be reported within 24 hours and that investigations begin as soon as a reportable event is known, with annual abuse training and additional in-services on abuse and reporting timelines. Staff member A stated that the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents, and confirmed that the time frames for reporting to the State Survey Agency are 2 hours for incidents involving serious bodily injury and 24 hours for incidents without serious bodily injury, with investigation findings due within 5 days. Record review showed that an incident of resident-to-resident abuse involving an altercation between residents #8 and #10, which occurred on 8/16/25, was not reported to the State Survey Agency until 8/18/25, exceeding the 24-hour reporting requirement. Review of the facility’s policy titled “Mandatory Reporting for Montana Nursing Facilities” confirmed that resident-to-resident abuse must be reported within 24 hours of discovery, that there is a 2-hour reporting requirement for crimes resulting in serious bodily injury, and that investigation results must be sent to the state agency within 5 working days of receipt of the abuse report. Despite these established policies and staff awareness of the required timelines, the facility did not submit the abuse incident involving residents #8 and #10 within the mandated 24-hour period from the date of the incident.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures during a COVID-19 outbreak. Observations revealed that visitors were not screened for COVID-19 symptoms upon entering the building, despite the presence of a sign-in log and N-95 masks at the entrance. Staff member J confirmed that no screening was in place, contrary to the facility's policy requiring active or passive screening. Additionally, transmission-based precaution signage was absent on the doors of COVID-19 positive residents, which led to staff being unaware of the specific precautions required. The facility also failed to practice proper hand hygiene during a laundry pass. Staff member G was observed distributing clothing to residents without performing hand hygiene before entering or after exiting resident rooms. Despite being educated on hand hygiene practices, staff member G admitted to forgetting the protocol. This oversight was in violation of the facility's hand hygiene policy, which mandates hand hygiene before and after entering resident rooms. Furthermore, the facility did not follow enhanced barrier precautions for residents with indwelling medical devices. Observations showed that resident #42, who had a foley catheter, did not have the required signage or personal protective equipment in place. Staff members were unsure why the necessary indicators were missing, despite the facility's policy and CDC guidelines requiring enhanced barrier precautions for residents with such medical devices.
Failure to Document COVID-19 Vaccine Declinations and Education
Penalty
Summary
The facility failed to document resident declinations and provide education regarding the COVID-19 vaccine for two of the five sampled residents. Resident #11 and Resident #27's preventive health care reports indicated that their resident representatives refused the administration of the COVID-19 vaccination. However, the facility did not provide signed declinations for these residents when requested during the survey. Additionally, staff member J confirmed that there were no signed declinations or documentation of education provided to the resident representatives for these residents. The facility's policy requires that if a resident or responsible party refuses an immunization, it must be documented in the permanent medical record, and the resident or responsible party should be provided with an education program and offered the immunization annually.
Failure to Implement Nutritional Interventions for Resident at Risk of Weight Loss
Penalty
Summary
The facility failed to follow outlined interventions for a resident who was at nutritional risk for weight loss. Observations revealed that the resident was not consuming meals provided, with a full breakfast tray left untouched and later removed while the resident was asleep. On another occasion, the resident was seen pushing food around without eating and later left her lunch untouched without any staff present to encourage or cue her to eat. The resident's care plan indicated she required encouragement during mealtimes and preferred finger foods due to her short attention span and frequent ambulation. The resident experienced a severe weight loss of 9.2% over three months, dropping from 106.4 lbs to 96.6 lbs. The facility's policy required weekly weight monitoring for residents with weight loss, but the resident's weight was only recorded monthly. A staff member mentioned that a new biweekly Resident at Risk meeting had identified the resident's significant weight loss, but the interventions were not effectively implemented, as evidenced by the observations of the resident's meal consumption.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that food items placed in the unit's nourishment refrigerator were properly dated and labeled with a resident's name. During an observation, an unlabeled and undated Tupperware container was found in the resident nourishment refrigerator, containing a homemade, unknown yellow liquid substance. There was no indication of which resident the food belonged to or how long it had been in the refrigerator. In an interview, a staff member stated that it was the responsibility of housekeeping to clean refrigerators in the resident common areas and mentioned that family members often placed items in the refrigerator without staff knowledge. The facility's policy on the use and storage of food brought in by family or visitors required all prepared food items to be labeled with content and dated, and consumed within three days, or else discarded by facility staff.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received, or had the opportunity to receive, the pneumococcal vaccine series. The immunization record for the resident showed that they had received one pneumococcal vaccine in 2018, but it did not specify the type of vaccine administered. A document titled 'Pneumococcal Vaccine Informed Consent/Decline' indicated that the resident's representative had consented for the resident to receive pneumococcal vaccines in 2024. During an interview, a staff member admitted that the facility did not keep pneumococcal vaccines in-house and had not yet arranged a vaccination clinic, citing being behind on reviewing immunizations. The facility's policy stated that residents should be assessed for vaccine eligibility within five working days of admission and offered the vaccine, but this was not adhered to in this case.
Failure to Monitor Cognitively Impaired Resident Leads to Elopement
Penalty
Summary
The facility failed to adequately monitor a cognitively impaired resident with a known history of elopement attempts, resulting in the resident leaving the building unsupervised. The incident was reported to the State Survey Agency after the resident was found alone at a nearby school playground. Staff interviews revealed that the resident was not residing in a secure unit, and there was a lack of awareness among staff members about the resident's elopement risk and the interventions in place to prevent such incidents. The resident in question had a history of wandering and required continuous supervision due to cognitive impairments, including fetal alcohol syndrome, schizophrenia, and moderate intellectual disability. The resident's care plan included interventions such as providing education on the importance of not leaving the facility, using verbal cues and gentle touch to redirect exit-seeking behaviors, and ensuring the resident did not accidentally follow visitors or pets out of the building. Despite these measures, several staff members were unaware of the resident's risk and the necessary interventions. Interviews with staff members indicated a lack of communication regarding residents at risk of elopement and their specific interventions. The facility had an elopement book intended to inform staff of at-risk residents, but it was not easily accessible, and several staff members were unaware of its contents. Additionally, the facility had not yet implemented an elopement huddle in morning meetings to improve communication about elopement risks, contributing to the oversight that allowed the resident to leave the facility unsupervised.
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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 Glasgow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Faith Lutheran Home | 29.1 mi | ★★★★★ | 9 | 0 |
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