Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Hi Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain effective fall precautions and supervision for two high-risk residents. One resident with dementia, hospice status, severe weakness, lethargy, and known impulsivity was care planned as a fall risk requiring monitoring in the bathroom, yet CNAs assisted her to the toilet and then left her unattended despite staff knowledge that she would attempt to get up on her own if kept waiting; she was later found on the bathroom floor with a head laceration and was pronounced dead. Another resident with a high fall-risk score and a prior fall had a physician order and care plan for a bed mobility alarm, but surveyors observed the bed alarm not functioning because it was unplugged, with the cord on the floor, contrary to orders requiring the alarm to be in place and functioning every shift.
A resident, admitted for short-term rehab, eloped from the facility after an exit door alarm was triggered. Staff failed to verify the resident's presence in nearby rooms and did not adequately check the area outside the alarming door. The resident was found outside, confused but unharmed, indicating a lapse in the facility's protocol for responding to door alarms.
A facility failed to resolve a grievance from a resident's POA about a lack of communication. Despite the care plan requiring immediate notification of any falls or changes in condition, the POA was not informed of a fall until several days later. This ongoing communication issue led to significant distress for the POA.
The facility did not ensure food was served at a safe temperature, resulting in a resident with cognitive impairment sustaining full thickness burns after spilling hot soup measured at 181.7°F. Additionally, improper use of mechanical lifts during resident transfers led to multiple injuries, including a resident with severe cognitive impairment who sustained bruises on her face. The incidents were attributed to inadequate temperature monitoring, lack of documentation, and failure to adhere to food safety and transfer protocols.
The facility failed to ensure that opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates and failed to discard an expired medication. This deficiency was observed in five residents who were prescribed various medications. The Director of Nursing confirmed that all medications need to be dated when opened, but the facility's policy lacked specific guidance on this matter.
The facility failed to screen for and offer the COVID-19 vaccine to four residents, as evidenced by the lack of documentation in their records. The Infection Preventionist confirmed that residents should be screened upon admission, but this was not done for the residents in question.
A resident's non-pressure sacral wound was not treated as ordered. The resident reported having a wound, and staff were observed applying cream, but no dressing was present. The Wound Care Nurse applied barrier cream instead of the prescribed Hydrogel and bordered foam dressing. The LPN confirmed that wounds should always have a dressing if ordered and that nurses are responsible for replacing it if missing.
The facility failed to maintain a catheter drainage bag below the bladder level for a resident during a transfer and bed bath, risking urine backflow and potential complications. The resident has a history of quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction.
The facility staff failed to ensure a resident took all medications during administration. An LPN left a cup of MiraLAX on the resident's table, which remained untouched. The DON confirmed that staff should stay with residents during medication administration and not leave medications unattended.
The facility failed to ensure PRN anti-anxiety medications had a duration/end date for two residents. One resident had an active order for lorazepam since July 2023, and another since February 2024, both without a stop date. The DON confirmed that PRN psychotropic medications should have a 14-day stop date, as per the facility's policy.
The facility failed to serve pureed barbecue beef brisket at safe temperatures to three residents. The cook recorded the food temperature at 130°F, below the required 135°F, and did not reheat it before serving. The Dietary Manager confirmed the need for food to be served above 135°F to prevent bacterial growth and foodborne illness, as per the facility's policy.
The facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for three residents requiring a pureed diet. The Dietary Manager confirmed the food was stringy and not smooth, increasing the risk of choking.
A resident's neurologist recommended physical therapy for lower extremity strengthening and balance, with an order placed and noted by staff. However, the facility failed to initiate the PT evaluation and treatment until over two months later, despite the Rehab Coordinator's statement that therapy evaluations should begin within a week of being ordered.
The facility failed to ensure that binding arbitration agreements were explained in a manner residents could understand. One legally blind resident signed without the agreement being read to her, and another resident signed without understanding it. The facility lacked a policy on these agreements.
The facility failed to screen for and administer influenza and pneumococcal immunizations to two residents. One resident did not receive the influenza vaccine until several months after consent and had not received the pneumococcal vaccine despite eligibility. Another resident was not re-screened for pneumococcal vaccine eligibility in subsequent years after an initial refusal by their POA.
The facility failed to ensure resident care equipment was in safe working order, leading to two incidents. In one case, a mechanical lift malfunctioned and pressed onto a resident's shoulder. In another, a resident fell due to a malfunctioning wheelchair brake. Both incidents were documented, and maintenance was notified.
The facility failed to provide mechanical lift training to staff members, resulting in an incident where a resident bumped her head on a Hoyer lift. The Home Health Aide involved had not received the necessary training, and the LPN and DON confirmed the lack of training. The resident's care plan required total mechanical transfers, but the facility did not ensure proper training for the staff.
Failure to Maintain Effective Fall Precautions and Supervision for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain updated and effective fall precautions and supervision for residents at risk for falls, resulting in a fall with head injury for one resident and an inoperative fall-prevention device for another. One resident (R1), who had unspecified moderate dementia with behavioral disturbance, a history of falls, and was on hospice with documented severe tiredness, lethargy, worsening loss of strength, and impulsivity, was known by multiple staff to be a “big fall risk,” impulsive, and likely to get up without waiting for assistance if call lights were not answered promptly. Her care plan identified her as at risk for falls due to unsteady gait and balance, with interventions including staff monitoring while in the bathroom and observation for gait unsteadiness, but the Assistant DON acknowledged that bathroom-related fall interventions had not been updated despite R1’s recent decline and change in bathroom habits. On the morning of 1/1/26, incident reports and staff statements show that a CNA (V5) responded to R1’s call light and screaming for help, found her in bed, and assisted her with a walker to the bathroom, placing her on the toilet and then leaving the room to attend to other tasks. Another CNA (V11) confirmed that R1 was clumsy with the walker and that both CNAs left the room to check on other residents while R1 remained on the toilet. A third CNA (V8) stated that R1 was using the bathroom and the CNA left her to answer another call light when the fall occurred. Staff interviews, including with the CNA supervisor (V4), multiple RNs (V6, V12, V14, V10), and the hospice RN (V16), consistently described R1 as clinically fragile, weak, lethargic, impulsive, and not willing to wait for help, and indicated that staff needed to stay close or in the room when she was in the bathroom. Despite this, R1 was left unattended on the toilet, and shortly thereafter staff found her on the bathroom floor on her left side with a head laceration and a puddle of blood under her head; she was described as nonresponsive, cyanotic, dusky, and with agonal breathing before being pronounced dead. A second resident (R3), also identified as at risk for falls with a fall risk assessment score of 16 and a prior documented fall from bed, had a care plan intervention and physician order for a bed mobility alarm with instructions that staff ensure the alarm was in place and functioning properly every shift. During the survey, R3 was observed in bed with a bed alarm attached to the bed rail, but the alarm indicator lights were not on. When the CNA supervisor (V4) checked the device, the alarm cord was found on the floor under the bed and not plugged in; once plugged in, the alarm light flashed red, indicating it had previously been off. The facility’s Fall Risk Assessment and Prevention Program policy requires individualized interventions for residents at risk for falls and evidence of care plan review and update following each fall, but in R3’s case the ordered bed alarm was not in place and functioning as required at the time of observation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to verify a resident had not eloped after an exit door alarm sounded and did not supervise the resident adequately to prevent elopement. The incident involved a resident who was cognitively intact and had been admitted for short-term rehabilitation following elective hip surgery. The resident was last seen in bed at 12:45 AM, and an alarm was triggered at 1:12 AM. Staff checked the door but did not see anyone outside due to darkness and silenced the alarm without verifying the resident's presence in nearby rooms. The resident was later found outside the facility, appearing confused but unharmed. Staff had not followed the facility's policy to check the immediate area outside the alarming door and verify the presence of residents in nearby rooms. The resident was brought back inside and assessed, showing no injuries. The incident highlighted a lapse in the facility's protocol for responding to door alarms and ensuring resident safety.
Failure to Resolve Grievance Regarding Communication
Penalty
Summary
The facility failed to resolve a grievance verbalized by a resident's POA regarding a lack of communication. The resident, who was cognitively impaired due to dementia and at risk for falls, experienced an unwitnessed fall in the bathroom. Despite the care plan indicating that the POA should be notified immediately of any falls or changes in condition, the POA was not informed of the fall until several days later. This delay in communication led to significant distress for the POA, who had previously expressed concerns about communication issues during a care plan meeting with the facility's administrators and DON. The POA had repeatedly communicated the need for immediate notification of any incidents involving the resident, yet the facility failed to adhere to this request. The incident report for the fall showed that the POA was not notified until much later, despite the facility's grievance policy stating that concerns should be addressed as quickly as possible. Interviews with facility staff confirmed that the POA's concerns about communication had been ongoing and that the facility had not taken prompt action to resolve these grievances, resulting in a deficiency in the facility's grievance resolution process.
Food Temperature and Mechanical Lift Safety Deficiencies
Penalty
Summary
The facility failed to ensure residents were served food at a safe temperature, leading to a resident (R273) sustaining full thickness burns on his right forearm and abdomen after spilling hot soup during a meal. The incident occurred when the soup was measured at 181.7 degrees Fahrenheit, well above the safe temperature range. The resident's cognitive impairment was not taken into account, as he continued to refuse to get up for meals, resulting in the burn incident. The lack of proper temperature monitoring and documentation, as well as the failure to follow established food safety policies, contributed to this serious safety issue. Additionally, the facility failed to safely transfer residents with a mechanical lift, resulting in multiple incidents where residents were injured during transfers. In one instance, a resident (R17) sustained a bruise below her left eye and on her forehead due to improper use of the mechanical lift. Despite the resident's severe cognitive impairment and the need for extensive assistance with activities of daily living, staff members were not cautious during transfers, leading to avoidable injuries. The facility's transfer and positioning policy emphasized the importance of extreme caution when using mechanical lifts, highlighting a clear deviation from established protocols.
Failure to Label and Discard Expired Medications
Penalty
Summary
The facility failed to ensure that opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates and failed to discard an expired medication. This deficiency was observed in five residents who were prescribed various medications. Specifically, an undated albuterol inhaler prescribed to one resident was found in a medication cart, and the LPN acknowledged that it should have been dated when opened. Another resident's Latanoprost eye drops were found opened and undated, and an albuterol inhaler prescribed to a third resident was found expired but not discarded. Additionally, an undated tube of Oragel prescribed to a fourth resident was found in the medication cart. The LPNs involved were unsure about the expiration dates of these medications once opened. The Director of Nursing confirmed that all medications need to be dated when opened to ensure proper expiration tracking, stating that most medications expire 28 days from opening, while inhalers expire 30 days from opening. The facility's Medication Pass Guidelines policy, dated April 2019, was reviewed and found to lack specific guidance on dating medications once opened and did not specify the expiration dates for oral gels or albuterol inhalers. This lack of proper labeling and discarding of expired medications led to the observed deficiencies in medication storage and management for the residents involved.
Failure to Screen and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to screen for and offer the COVID-19 immunization to residents, as evidenced by the lack of documentation for four residents (R64, R38, R59, R65) out of a sample of 18. R64's records showed no documentation of receiving or being offered the COVID-19 vaccine from admission until a progress note on 3/19/24 indicated a message left for the power of attorney regarding consent. Similarly, R38's records indicated no screening or offer of the vaccine from admission until a progress note on 3/20/24 showed a discussion with the resident about the vaccine. R59 and R65 also had no documentation of being screened or offered the vaccine until 3/19/24, despite being admitted earlier. The Infection Preventionist (IP) confirmed that residents are supposed to be screened for the COVID-19 vaccine upon admission and educated about it if needed. However, the IP was unable to find any documentation that the four residents had been screened or offered the vaccine. The facility's COVID-19 Response Plan stated that the vaccine should be made available to all employees and residents who wish to receive it, but this was not followed for the residents in question.
Failure to Treat Non-Pressure Sacral Wound as Ordered
Penalty
Summary
The facility failed to ensure a non-pressure sacral wound was treated as ordered for one resident. On 3/18/24, the resident reported having a wound on her bottom, and staff were observed applying cream to the area. However, the resident had no dressing on her sacrum as required by the treatment order. The Wound Care Nurse confirmed the presence of an open wound and applied barrier cream instead of the prescribed Hydrogel and bordered foam dressing. The treatment order specified that the wound should be washed with soap and water, patted dry, and Hydrogel applied, followed by a bordered foam dressing every three days or as needed. The Licensed Practical Nurse stated that a wound should always have a dressing if ordered and that nurses are responsible for replacing it if missing.
Improper Positioning of Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for a resident reviewed for catheters. During a transfer using a mechanical lift, CNAs hung the resident's catheter bag on the sling strap above the resident and later placed it on the bed while providing a bed bath. This improper positioning of the catheter drainage bag was observed by surveyors. A CNA confirmed that the catheter drainage bag should be positioned lower than the bladder to prevent urine backflow, which could lead to infections and other complications. The resident's medical history includes quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction. The facility's Foley Catheter Care Policy also mandates that the urinary catheter drainage bag should be kept lower than the bladder.
Failure to Ensure Resident Took All Medications
Penalty
Summary
The facility staff failed to ensure a resident took all medications during medication administration. On 3/19/2024 at 8:29 AM, an LPN prepared medications for a resident, including dissolving MiraLAX in water. The LPN administered the pills but left the MiraLAX on the resident's breakfast table in the dining room. The resident did not drink the MiraLAX, and the LPN was observed talking to other residents on the opposite side of the dining room. At 8:51 AM, the surveyor noted the MiraLAX was still untouched. When questioned, the LPN stated that he normally leaves the MiraLAX with the resident and checks back later. The Director of Nursing confirmed that staff should stay with residents during medication administration and that medications should not be left unattended. The facility's Medication Pass Guidelines policy states that staff should watch the resident swallow all medications and not leave any medications with the resident to take later.
Failure to Ensure PRN Psychotropic Medications Had a Stop Date
Penalty
Summary
The facility failed to ensure PRN anti-anxiety (psychotropic) medications had a duration/end date for two residents. One resident had an active order for lorazepam since July 2023, to be administered every two hours as needed for anxiety, agitation, or restlessness, without a stop date. Another resident had an active order for lorazepam since February 2024, to be administered every four hours as needed for anxiety, also without a stop date. The Director of Nursing confirmed that PRN psychotropic medications should have a 14-day stop date, as per the facility's policy reviewed in March 2022.
Failure to Serve Pureed Food at Safe Temperatures
Penalty
Summary
The facility failed to serve pureed barbecue beef brisket at safe temperatures to three residents on pureed diets. On the specified date, the cook recorded the temperature of the pureed barbecue beef brisket at 130°F, which is below the required 135°F for safe serving. Despite confirming the temperature, the cook did not reheat the food to the necessary internal temperature of 165°F before serving. The facility's temperature log from the previous day showed a different temperature for the same food item. The Dietary Manager confirmed that food should be served at temperatures above 135°F to prevent bacterial growth and foodborne illness. The facility's policy from 2017 mandates that hot food items must be cooked, held, and served at a minimum of 135°F.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for three residents requiring a pureed diet. On the specified date, the lunch meal tickets for these residents indicated they received pureed barbecue beef brisket. However, upon evaluation of a test tray, the pureed barbecue beef brisket was found to be stringy and not smooth, requiring chewing. The Dietary Manager confirmed that the consistency was improper and not in line with the facility's policy for pureed diets, which mandates that pureed foods should be completely smooth and semi-solid, similar to mashed potatoes. This inconsistency in food preparation increases the risk of choking for residents on a pureed diet.
Delay in Physical Therapy Evaluation and Treatment
Penalty
Summary
The facility failed to evaluate a resident for Physical Therapy (PT) after receiving an order to start PT. The resident's neurologist recommended dedicated physical therapy for lower extremity strengthening and balance, with an order placed on 10/4/23. The order was noted by staff on 10/5/23, but no evaluation or treatment for PT was initiated until 12/15/23. The PT evaluation and plan of treatment were conducted on 12/23/23, resulting in a delay of over two months. The resident's daughter confirmed that therapy was not started when ordered, and the Rehab Coordinator acknowledged that therapy evaluations should begin within a week of being ordered, indicating a significant delay in care.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was explained to residents in a form and manner they could understand. For one resident, who is legally blind, the agreement was not read to her, and she was unaware of what she was signing, believing it to be part of her admission paperwork. The concierge admitted to not reading the agreement to the resident and not knowing about her blindness. Another resident also signed the agreement without understanding it, thinking it was part of the admission paperwork. The facility did not have a policy on binding arbitration agreements, as confirmed by the administrator.
Failure to Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to screen for and administer influenza and pneumococcal immunizations to two residents. Resident 64 was admitted to the facility and had consent forms signed by their POA for both vaccinations. However, the resident did not receive the influenza vaccination until several months later and had not received the pneumococcal vaccination despite being eligible. The medication administration records confirmed the delay and omission of the vaccinations. Resident 19 was also not properly screened for pneumococcal vaccination eligibility. Although the resident's POA initially refused the vaccine, the resident had not been re-screened for eligibility in subsequent years. The facility's Infection Preventionist acknowledged the lack of a process for annual re-screening of long-term residents for pneumococcal vaccines and admitted that the facility missed administering the flu vaccine to Resident 64. The facility's policies indicated that vaccinations should be offered and administered to all qualifying residents and re-offered annually to those who refuse, but these policies were not followed in these cases.
Failure to Maintain Safe Resident Care Equipment
Penalty
Summary
The facility failed to ensure resident care equipment was in safe working order, affecting two residents. In the first incident, a mechanical lift malfunctioned while transferring a resident to bed. After the transfer was completed, the lift began to self-lower and pressed onto the resident's right shoulder. The resident did not sustain any injuries. The incident was reported, and the lift was taken out of service for maintenance. Interviews with staff confirmed that the lift's motor malfunctioned, causing the incident. The facility's mechanical work order indicated that the lift was under warranty and was being repaired by the manufacturer. In the second incident, a resident fell while being transferred from the toilet to a wheelchair due to a malfunctioning wheelchair brake. The right lock of the wheelchair was ineffective, causing the chair to move during the transfer. The resident was guided to the floor and did not sustain any injuries. The incident was documented, and maintenance was notified to fix the wheelchair brake. The facility's maintenance logs confirmed that the brakes were readjusted and tightened the following day. The facility's policy establishes a Preventive Maintenance Program to ensure regular inspection and testing of equipment.
Failure to Provide Mechanical Lift Training
Penalty
Summary
The facility failed to provide mechanical lift training to staff members using lifts for residents requiring mechanical lifts for transfers. This deficiency was identified during an interview and record review, where it was found that a Home Health Aide had not received any training on the Hoyer lifts from the facility. The aide, along with a Certified Nursing Assistant, was involved in an incident where the Hoyer lift started to tip, causing the resident to bump her head on the lift. The Licensed Practical Nurse/Rehab Coordinator confirmed that the aide likely did not receive the necessary training, and the Director of Nursing acknowledged that staff using a Hoyer lift should be trained. The resident's care plan indicated a need for maximum assistance with activities of daily living and required total mechanical transfers, but the facility failed to provide in-service training on Hoyer lifts for the involved staff member.
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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 Woodstock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hearthstone Manor | 4.3 mi | — | 0 | 0 |
| La Bella Of Woodstock | 4.5 mi | — | 12 | 0 |
| Mercy Harvard Hospital Care Center | 8.8 mi | — | 3 | 0 |
| Florence Nursing Home | 9.2 mi | — | 0 | 0 |
| Crystal Pines Rehab & Hcc | 11.4 mi | — | 4 | 0 |
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