Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
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 The Valley View Center For Nursing Care And Rehab during CMS and state inspections, most recent first.
The facility failed to develop and implement comprehensive behavior care plans for two residents with severe cognitive impairment and documented behavioral symptoms. One resident with Alzheimer’s disease and mobility issues had repeated episodes of wandering, resistance to care, confusion, agitation, and aggression documented by CNAs and nurses, yet no behavior care plan or ADL care plan notation of resistance to care was present in the EMR. Another resident with encephalopathy and severe cognitive impairment had multiple documented episodes of wandering, verbal and physical aggression, socially disruptive behavior, and resistance to care, and was identified as an elopement risk with an elopement care plan in place, but no behavior care plan was initiated. A unit manager stated that behavior care plans should be triggered by combative or aggressive behaviors and acknowledged that such plans were not created or updated for these residents despite the documented behaviors.
A resident with Alzheimer’s disease, severe cognitive impairment, delusions, and documented wandering behavior was assessed as high risk for elopement and had orders for frequent visual checks across all shifts. After an earlier incident where the resident was found off the unit in a kitchen area, staff were to perform 15‑minute visual checks, but documentation showed multiple omissions and no recorded checks during the later period when the resident left the unit and exited through a fire exit door. Video showed the resident self‑propelling a wheelchair outside onto the grounds and toward the employee parking lot before being assisted back inside by staff, while the door alarm sounded during change of shift and unit staff were unaware the resident had left. No active care plan specifically addressed wandering behavior at the time of the elopement, despite the resident’s high‑risk status and prior elopement‑related assessment findings.
A resident with Alzheimer's disease and a history of falls experienced a fall from a wheelchair. Following an occupational therapy assessment, a safety intervention was recommended to remove an additional mechanical lift pad after outside appointments to reduce fall risk. The care plan was not updated to include this intervention, despite facility policy and staff awareness.
The facility did not maintain adequate CNA and LPN staffing levels as outlined in its own assessment, leading to multiple shifts where staff numbers were below required minimums. As a result, residents did not receive essential medications, and staff reported frequent understaffing, mandatory overtime, and the need to cover multiple units. Administrative and nursing leadership confirmed these deficiencies and acknowledged that units were often left without proper nurse coverage.
A resident with severe cognitive impairment and physical disabilities was assisted with eating by an LPN who stood over them rather than sitting at eye level, contrary to facility policy. The LPN stated this was due to being the only nurse present and needing to assist multiple residents. The DON confirmed that staff should sit to ensure a dignified dining experience.
The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. The assessment lacked details on minimum staffing requirements for CNAs and LPNs, did not address behavioral health staffing, and omitted review dates and signatures with QAPI. The Administrator confirmed these omissions and cited reliance on PBJ reports and frequent staffing changes as reasons for not specifying exact staffing numbers.
Failure to Develop and Implement Behavior Care Plans for Residents With Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable behavior care plans for residents with severe cognitive impairment and documented behavioral symptoms. Facility policy required that a comprehensive care plan, including measurable goals and timetables, be developed within seven days after completion of the comprehensive assessment to address medical, nursing, mental, and psychosocial needs. Despite this, for two residents with Alzheimer’s disease, encephalopathy, and other conditions, there was no behavior care plan documented in the electronic medical record, even though both had repeated episodes of wandering, resistance to care, and verbal and physical aggression documented by CNAs and in nursing progress notes. One resident with Alzheimer’s disease, type 2 diabetes, and difficulty walking had an annual MDS showing severe cognitive impairment with inattention, disorganized thinking, delusions, and wandering. CNA documentation over a one‑month period showed frequent wandering and resistance to care across all shifts, and nursing progress notes recorded wandering and aggression on multiple dates, including an episode of confusion and agitation where the resident was fixated on missing belongings and past employment, requiring repeated phone calls to the spouse and 30‑minute visual checks. However, review of the resident’s care plans revealed no behavior care plan and no documentation in the ADL care plan that the resident was resistive to care. During interviews, a CNA and an LPN described the resident as confused, wandering, sundowning, repetitive, physically aggressive, and often refusing care, while the Unit Manager stated the resident did not have behaviors and acknowledged that no behavior care plan had been initiated. Another resident with encephalopathy, syncope and collapse, and difficulty walking had an admission MDS indicating severe cognitive impairment with inattention and disorganized thinking. Although initially documented as having no behaviors, subsequent CNA documentation over several days showed wandering, verbally and physically abusive behavior, socially inappropriate or disruptive behavior, and resistance to care on multiple shifts. Nursing progress notes also documented frequent attempts to leave the unit and episodes of verbal and physical aggression during morning care. The resident had an elopement risk order and a potential for elopement care plan with interventions such as structured activities, identification, 15‑minute visual checks, and a WanderGuard device, but there was no documented evidence of a separate behavior care plan in the electronic medical record. The Unit Manager explained that behavior care plans should be developed for combative or physically/verbally aggressive residents and confirmed that care plans are to be initiated and updated timely, but acknowledged that a behavior care plan had not been created for this resident.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as high risk. The resident had Alzheimer’s disease, severe cognitive impairment with inattention and disorganized thinking, delusions, and wandering behaviors occurring 1 to 3 days, as documented on an annual MDS. The resident used a wheelchair for locomotion, required supervision or assistance with most ADLs, was frequently or always incontinent, and had an order indicating they were incapable of making their own decisions. An elopement risk assessment showed a history of attempted elopement, wandering behavior, cognitive impairment, verbalizations about wanting to go home or leave the unit/building, and independent mobility, resulting in a high-risk elopement score of 19. Despite this high-risk status, the facility did not consistently implement and document required monitoring interventions. Following an incident on which the resident was found off their unit in the kitchen by dietary staff, the resident was placed on 15‑minute visual checks and identified as an elopement risk with a medical alert and visual check orders spanning all shifts. However, review of visual check documentation revealed omissions on multiple days, including 8/12/2025, 8/13/2025, and 8/14/2025, and there was no documentation of visual checks during the time period when the resident later eloped from 3:00 p.m. to 3:30 p.m. on 8/27/2025. Staff on the resident’s unit were not aware when the resident was off the unit during the earlier kitchen incident, and the DON acknowledged the lack of documentation for ordered visual checks. On 8/27/2025, video surveillance showed the resident exiting the building through a west wing fire exit door at 3:04 p.m., self‑propelling in their wheelchair onto the lawn and moving toward the employee parking lot, and then returning through the front entrance at 3:15 p.m. The Occupational Therapy Supervisor reported seeing the confused resident near the end of the employee parking lot and observing a social services staff member approach and assist the resident back toward the main entrance, after which therapy staff returned the resident to their unit and notified security. The DON and Administrator stated that the door alarm did sound when the resident exited, but staff may not have heard it because it was change of shift and staff were congregated near the nurse’s station. The DON also stated that an elopement risk assessment is completed on admission and after a resident wanders, and that the resident had been on visual checks since the earlier wandering incident, but could not recall whether the resident had a history of wandering beyond what was documented. Review of care plans showed no active care plan specifically addressing wandering behavior at the time, although a prior potential elopement care plan existed with interventions related to confusion/dementia and attempts to leave.
Failure to Update Care Plan After Fall and Therapy Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a comprehensive care plan was reviewed and revised to reflect a resident's current condition following a fall. The resident, who had diagnoses including Alzheimer's disease, dependence on renal dialysis, and a history of falls, experienced a fall from their wheelchair. After the incident, an occupational therapy assessment recommended that an additional mechanical lift pad, used during outside appointments such as dialysis, should be removed immediately upon the resident's return to reduce the risk of sliding forward and falling again. This recommendation was communicated to the nursing staff and the unit manager nurse. Despite the occupational therapist's recommendation and the facility's policy requiring care plans to be updated after a fall investigation, there was no documented evidence that the care plan was revised to include the new safety intervention. Both the occupational therapist and the unit manager nurse confirmed during interviews that the care plan did not reflect the recommended intervention, and the unit manager acknowledged responsibility for updating the care plan but had not done so.
Insufficient Nursing Staff Resulting in Missed Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as required by their own facility assessment and regulatory standards. On multiple occasions, the number of Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) scheduled for shifts fell below the minimums documented in the facility assessment. For example, on several evening and night shifts, the facility was short by several CNAs and LPNs compared to the required staffing levels. The facility assessment itself was not properly signed or reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee, and staff responsible for scheduling were unaware of the minimum staffing requirements outlined in the assessment. Due to these staffing shortages, there were documented instances where residents did not receive their prescribed medications, including critical drugs such as antibiotics, anticoagulants, insulins, and psychotropics. Interviews with residents confirmed that there were times when no nurse was present on their unit to administer medications, and some residents reported these issues to administration and during resident council meetings. Staff interviews corroborated these findings, with CNAs and LPNs reporting frequent understaffing, the need to split coverage across multiple units, and being mandated to work overtime or double shifts due to inadequate staffing. Administrative staff, including the Staffing Coordinator, Director of Staff Resources, Director of Nursing, and the Administrator, acknowledged the ongoing staffing issues and confirmed that units were often left without adequate nurse coverage. The Director of Nursing and Administrator both stated that the facility sometimes had to split nurses between units or have supervisory staff pass medications when regular staff were unavailable. The Union President and other staff also reported that complaints about short staffing and missed medications were common, particularly on the overnight shift.
Failure to Promote Dignity During Dining Assistance
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) was observed standing over a resident while assisting them with eating dinner, rather than sitting at eye level as required by facility policy. The resident involved had diagnoses including Alzheimer's disease with late onset, hemiplegia, hemiparesis, and dysphagia, and was documented as having severely impaired cognition and being dependent on assistance for eating. The LPN acknowledged awareness of the correct procedure but stated that due to being the only nurse on the floor and needing to assist multiple residents, they found it easier to stand while feeding. The Director of Nursing confirmed that staff are expected to sit and provide a comfortable dining experience for residents.
Incomplete Facility-Wide Assessment and Documentation Deficiencies
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations, including nights and weekends, and emergencies. The assessment did not address what constitutes sufficient staffing, particularly on weekends, nor did it differentiate the care required on weekend shifts from other shifts. Additionally, the assessment lacked information on the number of staff needed for behavioral health services and did not specify the minimum staffing requirements for Certified Nurses' Aides (CNAs) and Licensed Practical Nurses (LPNs). The assessment also omitted the date it was reviewed with the Quality Assurance and Performance Improvement (QAPI) committee and lacked signatures of approval. During interviews, the Administrator acknowledged that the facility assessment did not include the exact number of CNAs or LPNs required, citing frequent staffing changes and reliance on Payroll-Based Journal (PBJ) reports for staffing information. The Administrator was unable to provide documentation that the assessment was reviewed by QAPI and agreed that the assessment should have been signed and dated. The deficiencies were identified through record review and staff interviews during abbreviated surveys, with the most recent revisions of the facility assessment still lacking required details and documentation.
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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 Goshen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sapphire Nursing And Rehab At Goshen | 3.3 mi | — | 0 | 0 |
| Glen Arden Inc | 3.3 mi | — | 11 | 0 |
| Schervier Pavilion | 6.5 mi | — | 0 | 0 |
| Middletown Park Rehab & Health Care Center | 6.6 mi | — | 1 | 0 |
| Highland Rehabilitation And Nursing Center | 7.3 mi | — | 3 | 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 August 2026) and official state health department websites.