Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Arbor Care Center-valhaven, Llc during CMS and state inspections, most recent first.
A resident was exposed to a dish cart with very hot soapy water placed in the dining room near seated residents, and staff confirmed the water was accessible and could cause burns. The facility also failed to carry out planned fall-prevention measures for a resident with severe cognitive impairment and a history of multiple falls, as dycem was missing from the wheelchair cushion and red tape was not on the wheelchair brakes.
Late Reporting of Elopement and Resident Altercation: The facility failed to timely report an alleged elopement involving a resident with severely impaired cognition and wheelchair use, and also failed to submit a required 5-day report for a resident-to-resident altercation involving a resident with cerebral palsy, dysarthria, schizophrenia, anxiety, and depression. The elopement was reported to APS after the event, and the Administrator confirmed the altercation report was sent to the SA after the required deadline.
The facility failed to notify the Ombudsman of emergency transfers and discharges for multiple residents and failed to provide transfer documentation for two residents. Records showed residents were sent to the hospital or discharged home for issues including hypoxia, chest pain, kidney problems, pneumonia, right-sided weakness, altered mental status, and a hip fracture with severe cognitive impairment and total care needs. The Social Services Director stated they were not aware the Ombudsman needed to be notified, and the DON confirmed one transfer notification was not made.
A resident’s MDS inaccurately coded a stage 3 pressure ulcer as present on admission or reentry. The record showed the resident was admitted with a right buttock pressure ulcer, later had a new in-house acquired right buttock wound that became recurrent, resurfaced, and reopened, yet the annual MDS still marked the ulcer as POA. The NC confirmed the coding error.
Failure to Document Clinical Skills Competency for Nursing Staff: The facility did not have documentation showing clinical skills competency testing for 5 sampled nursing staff members, including MAs, an LPN, and an RN. Record review found no competency records in their personnel files, and the Nurse Consultant confirmed that clinical skills competency testing had not been conducted in the last year. The facility policy required training and competency documentation in personnel files.
A resident with severe cognitive impairment and repeated physical and verbal aggression toward others had multiple resident-to-resident altercations documented in the CCP and MDS. The facility’s interventions focused on separating residents and telling the resident to go to staff when frustrated, but staff did not identify behavior triggers or develop a behavioral management plan with non-pharmacological interventions and environmental adjustments, including consideration of the resident’s dining seat placement.
Staff training records showed missing annual abuse training for a NA and a MA, and incomplete dementia education for a NA, 3 MAs, and an LPN. One NA had no record of abuse or dementia training, and the other staff files showed limited dementia hours or no dementia training in the review period. The NC confirmed the missing abuse and dementia training during interview.
Nurse aides did not receive the required annual 12 hours of ongoing training for 2 sampled NA files. One NA had only 10 hours documented over the review period, and another NA had no documentation of ongoing training. The NC confirmed the deficiency, and the facility policy required 12 hours per year on job-related topics, including residents' physical, psychosocial, and mental needs.
Missing Nurse Aide Registry Checks for Two Employees: The facility failed to verify the Nurse Aide Registry for 2 of 5 sampled employee files. A HK and an NA each had a hire date in their file, but no registry check was present. The NC confirmed the registry was not checked for either employee before they worked directly with residents.
The facility failed to maintain proper kitchen hygiene practices, as observed with staff not wearing required hair and beard nets and not adhering to hand hygiene protocols. The Dietary Manager and other kitchen staff were seen without appropriate protective gear and did not follow the facility's handwashing policy, potentially risking food contamination.
The facility experienced a delay in the activation of its emergency power system during a power outage, resulting in a two-minute period without power for emergency exit signs, lighting, and medical equipment. Staff had to manually switch residents requiring oxygen to portable tanks. The facility's policy requires immediate notification of the Administrator and Maintenance Director if the generator fails to activate within 10 seconds.
A facility failed to document the use of a wander guard for a resident with severe cognitive impairment in their MDS, despite the resident being observed with the device and care plans indicating its use. This oversight was confirmed by a nurse, highlighting a deficiency in accurate resident assessment.
A resident was admitted to the facility without a required PASARR Level II evaluation, despite having diagnoses that should have triggered it. The facility's policy requires coordination with the PASARR program to ensure appropriate care for residents with mental disorders or intellectual disabilities, but the initial screen failed to include the necessary diagnoses, leading to a deficiency.
Two residents experienced medication administration errors, leading to a facility medication error rate of 6.67%. One resident received Hydrocortisone cream incorrectly applied, while another had enteric-coated Aspirin improperly crushed and administered. These errors were confirmed by the DON.
An Infection Preventionist in an LTC facility failed to change gloves and perform hand hygiene after emptying a resident's urostomy bag, leading to a deficiency in infection control. The IP used the same gloves to offer the resident water, which was refused. Interviews confirmed the need for proper hand hygiene practices.
Hot Water Exposure and Missing Fall Prevention Interventions
Penalty
Summary
The facility failed to keep hot water away from vulnerable residents in the dining room. During lunch service, kitchen staff had a cart with three plastic tubs of soapy water with visible steam rising from the surface positioned in the dining room beside the doorway to the dishwashing room. The water temperatures were measured at 150.9 degrees, 158.7 degrees, and 161.1 degrees. A resident who was independently mobile with a walker was seated at a nearby table, and staff confirmed the hot water was accessible to residents in the dining room and could cause burns to an elderly person's skin. Staff interviews showed the cart was routinely used for dirty dishes and that the hot water was intentionally prepared to help dissolve leftover food on plates. The dietary aide confirmed the tubs were placed outside the kitchen door leading to the dishwashing station, and the dietary manager confirmed the cart was in the dining area and that the temperatures sounded about right. Nursing staff who were assisting residents during the meal stated they were not responsible for monitoring the hot water and were not aware that the tubs contained very hot water. The facility also failed to implement fall prevention interventions for a resident with severe cognitive impairment and a history of multiple falls, including a fractured left femur from a recent fall. The resident's care plan identified interventions including dycem on the wheelchair cushion and red tape on the wheelchair brakes, but observations on multiple occasions showed these items were not in place. Staff confirmed the resident was supposed to have dycem and red tape on the wheelchair brakes, and one medication aide stated they had no knowledge of those interventions being needed.
Late Reporting of Elopement and Resident Altercation
Penalty
Summary
The facility failed to notify the State Agency of an alleged elopement within the required time frame for Resident 17. Resident 17 had severely impaired cognition with a BIMS score of 7 and used a wheelchair. The resident’s care plan documented that the resident eloped out of the 200 Hall exit, and a progress note stated the resident exited through the back door. The elopement report showed APS was called the following day, and the DON confirmed the report was not called in at the time of the elopement because the DON was asleep when the floor nurse texted about the event. The facility also failed to submit a written report for a resident-to-resident altercation within 5 days for Resident 5. Resident 5 had diagnoses including cerebral palsy, dysarthria, paranoid schizophrenia, generalized anxiety disorder, and major depressive disorder, and had a BIMS score of 10 indicating moderately impaired cognitive function. The investigation documented that Resident 5 struck another resident’s right upper arm during an interaction, but the 5-day investigation was not transmitted to the State Agency until 6 days after the incident. The Administrator confirmed the report was sent late and should have been submitted by the required deadline.
Failure to Notify Ombudsman and Provide Transfer Documentation
Penalty
Summary
The facility failed to provide reports to the receiving facility for emergency transfers for two residents and failed to notify the Ombudsman of transfers or discharges for four residents. Record review and interviews showed that one resident was admitted to the hospital for significant hypoxia and chest pain, another resident was hospitalized for kidney issues and a provider note also documented pneumonia, a third resident was sent to the emergency room for right-sided weakness and altered mental status, and a fourth resident discharged home. The medical charts for these residents did not contain progress notes confirming that the Ombudsman had been notified of the discharges, and the Social Services Director stated they were not aware the Ombudsman needed to be notified of resident discharges and did not send notifications for these residents. For another resident, the MDS showed severe cognitive impairment, recent hip fracture surgery, and total assistance needs for hygiene, toileting, dressing, bathing, and transfers. A progress note documented that the resident was transferred to the hospital, but the progress notes did not indicate that the Ombudsman had been notified of the transfer. The DON confirmed that the Ombudsman had not been notified of the transfer and should have been. The facility policy stated that the Social Services Director or designee would provide copies of notices for emergency transfers to the Ombudsman, and that they could be sent when practicable, such as on a monthly list if all required content was included.
Incorrect MDS Coding of Pressure Ulcer Present on Admission
Penalty
Summary
The facility failed to accurately enter pressure ulcer information on the Minimum Data Set (MDS) for one resident. Record review showed the resident was admitted with a diagnosis of a stage 3 pressure ulcer of the right buttock, and the facility policy required staff completing MDS sections to attest to the accuracy of the information and follow the current RAI manual for coding assessments. The RAI manual states that for each pressure ulcer or injury, staff must determine whether it was present on admission or acquired while the resident was in the nursing home, considering current and historical tissue involvement. For this resident, the record showed a right buttock pressure ulcer that was identified by the facility as a new, in-house acquired wound in 2023, later documented as recurrent, resurfaced, and then reopened in 2025. Despite this history, the annual MDS coded the stage 3 pressure ulcer as present on admission or reentry. During interview, the Nurse Consultant confirmed the pressure ulcer on the MDS was incorrectly coded as present upon admission or reentry.
Failure to Document Clinical Skills Competency for Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had appropriate competency testing for clinical skills for 5 of 5 sampled nursing staff files. Record review showed no documentation of clinical skills competency testing in the personnel files of MA E, MA F, MA G, LPN H, and RN I, despite their hire dates ranging from 2016 through 2025. During interview, the Nurse Consultant confirmed on 08-12-2025 at 11:30 AM that competency testing of clinical skills had not been conducted in the last year. The facility policy titled Training Requirements stated that the facility must develop, implement, and maintain an effective training program for all new and existing staff and that competencies and skill sets must be consistent with expected roles, with documentation placed in the personnel file.
Failure to Develop Behavioral Management Plan for Resident with Repeated Aggression
Penalty
Summary
The facility failed to develop and implement a behavioral management plan for Resident 12, who had severe cognitive impairment with a BIMS score of 7 and documented behavioral symptoms directed toward others. The resident’s MDS also indicated physical and verbal behavior symptoms toward others several days a week, that the behavior put the resident at significant risk for physical illness or injury, significantly interfered with care and participation in activities or social interactions, and had worsened. The resident required partial assistance with toileting, bathing, and dressing, and set-up and supervision with eating and hygiene. The care plan identified repeated resident-to-resident altercations, including incidents in which Resident 12 hit other residents in the leg, stomach, face, and arm, including one event described as unprovoked and another during the noon meal when another resident was tapping fingers on the table. The care plan goal was that Resident 12 would not hit another resident, and the listed interventions focused on separating residents, offering 1-to-1 activities if agitated, encouraging the resident to go to nursing staff with concerns, directing the resident to the room when frustrated, and telling the resident not to touch others. The facility also contacted the guardian for a psychiatric evaluation after one incident. Survey observations showed Resident 12 seated in the dining room in a position that placed the resident’s back to the aisle between tables, and the resident was sitting far enough away from the table to encroach on the aisle. During interview, the DON and NC stated the facility had not identified the triggers for the resident’s aggressive behavior and had not considered moving the assigned dining seat to reduce those triggers. The DON also confirmed that the same intervention of educating the resident to go to staff when frustrated was used after repeated aggressive behavior, and that a behavior management plan had not been developed to include non-pharmacological interventions and environmental adjustments.
Staff Training Deficiencies for Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure ongoing abuse training for 2 of 8 sampled staff files, including a NA and a MA, and failed to ensure ongoing dementia training for 5 of 8 sampled staff files, including a NA, 3 MAs, and an LPN. Record review showed the NA had a hire date of 07-02-2024 and no record of abuse or dementia training. The MA had a hire date of 07-24-2019, a Course Completed History dated 06-04-2025 showing 1.25 hours of ongoing training from 03-14-2024 to 08-06-2025, 1 hour of dementia training, and no abuse training recorded. Record review also showed another MA had a hire date of 09-24-2019 and a Course Completed History dated 06-04-2025 showing 5.75 hours of ongoing training from 01-13-2024 to 08-06-2025 with only 1 hour of dementia training completed. A third MA had a hire date of 04-20-2016 and a Course Completed History dated 06-04-2025 showing 1.0 hour of ongoing training from 02-29-2024 to 08-06-2025 with no dementia training completed. The LPN had a hire date of 03-17-2022 and no record of dementia training in the last year. The NC confirmed on interview that the NA and MA did not have annual abuse training and that the NA, 3 MAs, and the LPN did not have 4 hours of ongoing dementia training.
Nurse Aide Ongoing Training Deficiency
Penalty
Summary
The facility failed to ensure nursing assistants had 12 hours of ongoing training per year for 2 of 2 sampled nurse aide files, NA C and NA D. Record review showed NA C was hired on 07-22-2022 and had a Course Completed History dated 06-04-2025 showing only 10 hours of ongoing training completed from 01-03-2024 to 08-06-2025. Record review of NA D showed a hire date of 07-02-2024 and no documentation of ongoing training. During an interview on 08-11-2025 at 2:30 PM, the Nurse Consultant confirmed that NA C and NA D did not complete 12 hours of ongoing training annually. The facility policy dated 09-2024 stated that ongoing training for nurse aides must consist of 12 hours per year on topics appropriate to the employee's job duties, including meeting the physical, psychosocial, and mental needs of residents.
Missing Nurse Aide Registry Checks for Two Employees
Penalty
Summary
The facility failed to check the nurse aide registry for 2 of 5 sampled employee files. Record review of the facility policy titled Staffing Requirements dated 09-2024 showed that employment eligibility requires evidence of registry checks, including the Nurse Aide Registry, Adult Protective Services Central Registry, Central Registry of Child Protective Services, and the Sex Offender Registry. Record review of the facility policy titled Background Investigations dated 10-10-2025 stated the facility will not employ individuals with findings in the state nurse aide registry concerning abuse, neglect, exploitation, misappropriation of property, or mistreatment by court of law. Review of Housekeeper A's employee file showed a hire date of 07-15-2025 and no nurse aide registry check. Review of Nursing Assistant B's employee file showed a hire date of 05-05-2025 and no nurse aide registry check. The Nurse Consultant confirmed on 08-11-2025 at 2:00 PM that the nurse aide registry was not checked for Housekeeper A and Nursing Assistant B and should have been checked before they worked directly with residents.
Deficiencies in Kitchen Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment protocols in the kitchen, which could potentially lead to food-borne illnesses affecting all residents. Observations revealed that the Dietary Manager (DM) was seen without a beard net during breakfast and lunch meal preparations. Additionally, Cook-I was observed washing hands inadequately for only 10 and 6 seconds before handling food, contrary to the facility's expectation of a 30-second hand wash. Cook-K was also noted to have returned from a break and handled clean plates without washing hands, which was confirmed as a lapse in protocol by Cook-K. Further observations showed that both the Dietary Aide (DA) and Cook-L entered the kitchen without hair nets during lunch service, and neither performed hand hygiene upon entering. Interviews with the staff confirmed their awareness of the requirement to wash hands and wear hair restraints, as outlined in the facility's policies. The facility's hand hygiene policy, updated in 2021, specifies a minimum of 15 seconds for handwashing, and the dietary employee personal hygiene policy mandates the use of hair restraints to prevent contamination.
Emergency Power System Delay During Outage
Penalty
Summary
The facility failed to ensure that the emergency electrical power system activated within the required 10 seconds during a power outage, affecting all residents. On the day of the incident, a complete power outage occurred at 10:00 AM, and the emergency generator did not become operational until 10:02 AM. During this two-minute interval, there was no electrical power to supply emergency exit signs, lighted means of egress, or any electric-powered medical equipment, such as oxygen concentrators. Nursing staff had to manually switch residents who required oxygen to portable tanks or connect their concentrators to emergency outlets. The facility's Administrator confirmed the power loss and acknowledged that the generator should have activated within 10 seconds. A review of the facility's policy on emergency generator malfunction indicated that the Charge Nurse should contact the Administrator and Maintenance Director if the generator fails to restore power within the specified time. Additionally, the facility's Emergency Generator Monthly Test Log showed that the generator typically activated within 3-5 seconds, indicating a deviation from the norm during the incident.
Inaccurate MDS Documentation for Resident's Personal Alarm
Penalty
Summary
The facility failed to accurately document the use of a personal alarm for a resident in their Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning. The resident in question, identified as Resident 18, was admitted with multiple diagnoses including dementia, schizoaffective disorder, obsessive-compulsive disorder, vascular dementia, and major depressive disorder with severe psychotic symptoms. Despite these conditions and a documented risk of elopement, the MDS inaccurately indicated that a wander guard was not used, even though the resident was observed wearing one. The deficiency was further highlighted by a review of the resident's care plan and physician's orders, which both confirmed the use of a wander guard as an intervention for elopement risk. An interview with a registered nurse confirmed that the MDS should have been marked to reflect the use of the wander guard, but it was not. This oversight in documentation represents a failure to ensure that the resident's assessment was accurate and complete, as required by regulatory standards.
Failure to Complete PASARR Level II Evaluation for Resident
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening Resident Review (PASARR) for a resident, leading to a deficiency in ensuring appropriate care and services for individuals with mental disorders or intellectual disabilities. The facility's policy mandates coordination with the PASARR program to ensure residents with mental disorders or intellectual disabilities receive care in the most integrated setting. However, during a record review, it was found that the PASARR screen for a resident admitted with diagnoses including anxiety disorder, panic disorder, delusional disorder, and post-traumatic stress disorder did not trigger a Level II evaluation, which should have been completed prior to admission. An interview with a registered nurse confirmed that the initial PASARR screen failed to include the resident's admission diagnoses, which would have necessitated a Level II evaluation. This oversight resulted in the resident being admitted without the required comprehensive evaluation by the state-designated authority. The resident's medical record showed no subsequent PASARR screens since the initial one, indicating a lapse in compliance with the facility's policy and federal requirements.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate below 5%, resulting in a rate of 6.67% during the survey. Two medication errors were identified among the nine residents sampled. The first error involved Resident 148, who had an order for Hydrocortisone External Cream 2.5% to be applied topically to hemorrhoids every 8 hours as needed. However, the medication aide incorrectly administered the cream by squeezing it directly onto the rectal area without applying it with gloved fingers, as required by the facility's protocol. This improper application was confirmed as a medication error by the Director of Nursing. The second error involved Resident 31, who had an order for Aspirin EC 81 mg to be taken orally once a day without crushing. During medication administration, the resident began to chew and spit out a Tylenol tablet, prompting the medication aide to crush all of the resident's medications, including the enteric-coated Aspirin, and mix them with applesauce. This action was contrary to the medication order and was confirmed as a medication error by the Director of Nursing. Both errors contributed to the facility's medication error rate exceeding the acceptable threshold.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility staff failed to ensure proper hand hygiene and glove changes during personal care for a resident, leading to a deficiency in infection prevention and control. The incident involved an Infection Preventionist (IP) who entered a resident's room and put on gloves without washing hands. The IP then gathered paper towels and a graduate cylinder, placed them on the resident's bedside tray table, and proceeded to empty the contents of the resident's urostomy bag into the graduate cylinder. After completing this task, the IP removed the gloves and washed hands with soap and water for more than 20 seconds before donning new gloves, an isolation gown, and a face shield. However, the IP failed to change gloves and perform hand hygiene after emptying the urostomy bag and before offering the resident a drink of water. The IP used the same gloves to handle the water pitcher and straw, attempting to give the resident water multiple times, which the resident refused. Interviews with the IP and the Director of Nursing confirmed that the IP should have changed gloves and performed hand hygiene after handling the urostomy bag contents.
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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 Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Elkhorn | 6.4 mi | ★★★★★ | 27 | 0 |
| Brookestone Meadows Rehabilitation And Care Center | 7.2 mi | ★★★★★ | 0 | 0 |
| The Lighthouse At Lakeside Village | 9.7 mi | ★★★★★ | 2 | 0 |
| Nye Pointe Health & Rehab Ctr | 12 mi | ★★★★★ | 7 | 0 |
| Newport House | 12.2 mi | ★★★★★ | 8 | 0 |
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