Valhalla Post Acute

In the surveyor’s words

From the most serious findings on record at Valhalla Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 17, 2024

  Based on observation, interview, and record review, it was determined the facility failed to provide a safe environment for residents. The facility's deficient practice had the potential to affect 24 of 24 residents who resided on the English Oak Terrace Unit. On 05/01/2024 a staff member was arrested under suspicion of arson after a fire occurred in Resident (R14) and R466's room. The facility failed to protect residents when a staff member, the Social Services Assistant (SSA), voiced frustration and threatened Resident (R) 14. On 05/01/2024 at approximately 4:45 PM, the Social Services Assistant (SSA) exited an elevator and stated to Certified Nursing Assistant (CNA) 2 he was going to get rid of R14. […]

• Immediate jeopardy, isolatedF835Feb 6, 2024

  Based on interviews, record reviews, and facility document and policy review, it was determined the facility failed to ensure that the Administrator of the facility took proper measures to ensure the safety of a resident for 1 (Resident #112) of three (3) sampled residents reviewed for elopement. Specifically, Resident #112, whom the facility assessed to have moderately impaired cognition and developed a care plan that directed staff to supervise the resident as needed, left the facility without notifying staff on 05/09/2021. The facility failed to notify the police that the resident was missing until approximately 18 hours after the resident left the facility. On 05/10/2021 at approximately 10:00 AM, Resident #112 was found on the side of a highway. […]

• Immediate jeopardy, isolatedF837Feb 6, 2024

  Based on interviews, record reviews, and facility document and policy review, it was determined the facility's governing body failed to ensure policies regarding the management and operation of the facility were implemented. The governing body was aware that on 05/09/2021, at approximately 6:00 PM, a resident whom the facility assessed to have moderate cognitive impairment left the facility and was missing. The facility failed to implement its missing resident protocol and notify the police of the missing resident. The governing body was aware that the facility concluded Resident #112 left against medical advice (AMA) and took no further action to find the resident. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2024

  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. […]