Valhalla Post Acute

Based on observation, interview, and record review, the facility failed to provide food that was palatable. This had the potential to affect all residents receiving meals in the facility. The findings include:Review of the facility's Food and Nutrition Services policy (Administrative Policy and Procedure Manual for Long-Term Care, Version 2.3, October 2017) revealed the facility policy included that the facility will make reasonable efforts to accommodate resident choices and preferences; staff inspected food trays to ensure the correct meal was provided to residents and that food was served safe and at appetizing temperatures. Other provisions included nursing staff reported to the food service manager delivery of incorrect meals or meals that did not appear palatable; nourishing snacks would be available to residents 24 hours daily; and the food services department will offer a variety of foods from the basic food groups at each meal and provide access to nourishing snacks. Further review revealed resident input was considered during meal planning. A test tray observation during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility's policies, it was determined the facility failed to ensure that one (1) out of twenty-one (21) sampled residents, Resident (R)5, received proper treatment and care to maintain mobility and good foot health by failing to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s). The findings included:Review of the facility's policy titled, Wound Care, dated 10/2010, revealed that the purpose of the policy was to provide guidelines for the care of wounds to promote healing. Further review revealed that staff should verify the physicians order prior to wound care. Per the policy, documentation of wound care should be recorded in the resident's medical record.Review of R5's Face Sheet revealed that he was admitted to the facility on [DATE] with diagnoses including tobacco use, hypertension, diabetes mellitus type II with hyperglycemia (high blood sugar)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDEDBased on observation, interview, and review of the facilities policy the facility failed to store and prepare food in accordance with professional standards for food service safety which had the potential to affect 144 residents who consumed food from the kitchen. The findings include:Review of the facility's policy titled, [NAME] Corporate Dieticians Policy 152-Food Storage, revised 07/11/2024, revealed opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated. Also to rotate stock utilizing first in and first out rotation. Further inquiry revealed no further policies on food handling. Observation on 05/11/2025 at 5:00 PM revealed in a walk-in refrigerator an opened container of a 2-pound roast beef with no epiration date. Further observations revealed a ham labelled as cheese wrapped in plastic wrap and dated 05/08/2025; pepperoni in plastic wrap undated and opened Two pieces of melon, wrapped separately in plastic wrap but undated and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to ensure a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12 months for four out of five CNA's personnel records reviewed, CNA7, CNA8, CNA9, and CNA10. The finding include: Review of the facility's policy, titled, Performance Evaluations, revised, September 2020, revealed, The job performance of each employee shall be reviewed and evaluated at least annually. Additionally, the policy stated, A performance evaluation will be completed on each employee at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. Furthermore, the policy indicated performance evaluations may be used to improve the quality of the employee's work performance. Review of CNA7's personnel file revealed a hire date of 12/07/2023. For dates of 12/07/2023-12/07/2024, there was a completed paper packet of annual training for 13 hours. However, there was no documentation for a performance evaluation in that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide a safe environment for residents. One sampled resident (Resident (R) 57) was not assessed for smoking, in accordance with facility policy. This non-smoking facility failed to ensure that incendiary devices (lighters) were not accessible to R57, who was involved in two separate instances of fire in his room. R57 was found to be in possession of cigarettes and a lighter after a fire in his bathroom on 04/15/2024. The following day, 04/16/2024, R57 had a fire in his closet. This failure to assure lighters were secured had the potential to affect six additional sampled residents (R40, R503, R14, R87, R504, and R506) as well as up to 58 residents who resided on one of four units (English Oak Terrace (EOT)) which was evacuated due to the fires, out of a total census of 150 residents. The findings include: Review of the facility's policy, Smoking Policy - Residents, revised 02/28/2024, revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review it was determined that the facility failed to ensure staff stored, prepared, and served foods for 152 of 152 residents in a sanitary manner. Kitchen staff failed to implement proper hand hygiene practices during meal service to prevent potential contamination. Staff failed to ensure food items were not contaminated during food preparation when staff used a knife while handling raw meat, then without sanitizing, used the same knife to slice cooked meatloaf. In addition, staff should ensure that personal jewelry should not touch resident's food. Furthermore, staff should ensure that all food stored in the nourishment room refrigerators are properly labeled and dated and discarded if expired. The findings include: 1. Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, revealed 7. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. On 02/01/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code it was determined the facility failed to ensure 3 of 3 dumpsters were closed and the area around them was free of trash, and the elimination of debris prevented the potential for vermin and pest attraction. This had the potential to affect all 155 of 155 residents who resided in the facility. The facility failed to provide dumpters. The findings included: Review of Chapter 5. Water, Plumbing, and Waste, section 5-5 Refuse, Recyclables, and Returnables of the U.S. FDA 2022 Food Code, dated 01/18/2023, revealed, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure Medication Aide (MA) #58 did not allow two (2) of three (3) residents (Resident #96 and Resident #18)observed during medication administration to self-administer their own medications. There were no physicians' orders and interdisciplinary team assessments to determine if the residents were able to safely do so. The findings include: A review of a facility policy titled Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy also specified, 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. Review of Resident #96's admission Record revealed the facility admitted the resident on 10/07/2021. According to the admission Record, the resident had a medical history that included diagnoses of chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, document reviews, video camera footage, interviews, and facility policy review, it was determined the facility failed to ensure (one) 1 of seven (7) sampled residents, Resident #311, reviewed for abuse was free from physical abuse. On 09/13/2022 at approximately 3:30 PM, Resident #311's Power of Attorney (POA) met with Administrator #77 and alleged Certified Nursing Assistant (CNA) #74 smacked at the resident's legs while care was being provided. The POA also alleged that another CNA ate food that was on the resident's meal tray and another CNA handled the resident roughly while care was being provided. Per the initial report, the three (3) staff identified were CNA #74, CNA #75, and CNA #76. The facility provided video coverage of the incident for State Survey Agency (SSA) Surveyor review. The findings include: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure proper placement of a stability boot for one (1) of thirty-one (31) sampled residents, Resident #68. The findings include: A review of a facility policy titled, Medication and Treatment Order, revised in July 2016, revealed Orders for medications and treatments will be consistent with principles of safe and effective order writing. A review of Resident #68's admission Record revealed the facility admitted the resident on 06/15/2022. The admission Record revealed the resident had diagnoses to include a fracture of the right fibula, fracture of the lateral malleolus (bone on the outside of the ankle) of the right fibula, and displaced fracture of medial malleolus of the right tibia. A review of Resident #68's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure one (Resident #463) of five (5) sampled residents reviewed for advance directors, with physician's orders that accurately reflected the resident's code status. The findings included: A review of the facility's policy titled, Do Not Resuscitate Order, revised in [DATE], revealed, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. A review of Resident #463's admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included metabolic encephalopathy, cognitive communication deficit, and unspecified dementia. A review of Resident #463's Resuscitation Designation Form dated [DATE], revealed the resident had the code of do not resuscitate and wished for cardiopulmonary resuscitation (CPR) not to be initiated in the event they were found without a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure staff administered tube feeding formula at the rate prescribed by the physician. The facility also failed to accurately and consistently monitor the amount of tube feeding formula infused each shift to ensure one (Resident #135) of two (2) sampled residents reviewed for tube feedings consistently received the amount of tube feeding formula recommended by the Registered Dietitian (RD) and as ordered by the physician. The findings included: A review of the facility's policy titled Enteral Nutrition, revised in November 2018, revealed, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation 1. The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The policy further indicated, 3. The dietitian, with input from the provider and nurse: a. Estimates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure proper respiratory care was provided to three (3) of five (5) sampled residents (Residents #62, #127, and #57) reviewed for respiratory care. The findings include: 1. A review of a facility policy titled Tracheostomy Care, revised in October 2023, revealed, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. The policy further revealed, A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. The policy revealed the Procedure Guidelines for Preparation and Assessment included Check the physician order. The policy revealed it did not specifically address the proper storage of respiratory equipment, to include a suction machine. A review of Resident #62's admission Record revealed the facility admitted the resident on 09/24/2018, with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.