Inspection Reports for Valhalla Post Acute
300 SHELBY STATION DRIVE, LOUISVILLE, KY, 40245
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found the facility in substantial compliance with no deficiencies. This follows a similar result from the prior inspection on May 2, 2025, which also identified no deficiencies. Earlier complaint investigations were not noted in the available reports, and no enforcement actions such as fines or license suspensions were listed. Inspectors did not cite any issues related to resident care, safety, or documentation during these reviews. The inspection history indicates consistent compliance with regulatory requirements over this period.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
135 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 1
Aug 8, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, focusing on the facility's provision of appropriate foot care and wound treatment for residents.
Findings
The facility failed to ensure that one resident (R5) received proper foot care and wound treatment as ordered, resulting in multiple missed treatments documented in the Treatment Administration Records over several months. The missed care posed a risk of worsening wounds and potential infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate foot care and wound treatment as ordered for Resident R5, including multiple missed treatments documented in the Treatment Administration Record. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed wound care treatments: 61
Sampled residents: 21
Missed treatments in July 2025: 10
Missed treatments in June 2025: 4
Missed treatments in March 2025: 13
Missed treatments in January 2025: 6
Missed treatments in December 2024: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Spoke with Resident R5 about wound care concerns and communicated with nursing staff. |
| LPN5 | Licensed Practical Nurse | Reported that Resident R5 went to outside podiatry for wound care. |
| Associate Director of Nursing | Associate Director of Nursing (ADON2) | Investigated missed wound care documentation and explained issues with agency nurses and EMR access. |
| Director of Nursing | Director of Nursing (DON) | Expected staff to follow wound care orders and document treatments; discussed challenges with agency staff documentation. |
| Administrator | Facility Administrator | Stated wound care should be done as ordered and emphasized the importance of investigating missed treatments. |
Inspection Report
Abbreviated Survey
Census: 135
Deficiencies: 0
May 28, 2025
Visit Reason
An Abbreviated Survey was conducted from 05/23/2025 through 05/28/2025 to investigate KY00046173 and KY00046065.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to KY00046065 or KY00046173.
Report Facts
Sample Size: 5
Inspection Report
Routine
Deficiencies: 2
May 14, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including staff performance evaluations and food storage and preparation standards.
Findings
The facility failed to ensure annual performance evaluations were completed for four out of five Certified Nursing Assistants reviewed, and failed to store and prepare food in accordance with professional standards, potentially affecting 144 residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete annual performance evaluations for four out of five Certified Nursing Assistants. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store and prepare food in accordance with professional standards, including unlabeled and undated food items and spoiled mushrooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 144
Certified Nursing Assistants reviewed: 5
Certified Nursing Assistants without annual evaluation: 4
Annual training hours: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA7 | Certified Nursing Assistant | Personnel file reviewed showing no annual performance evaluation |
| CNA8 | Certified Nursing Assistant | Personnel file reviewed showing no annual performance evaluation |
| CNA9 | Certified Nursing Assistant | Personnel file reviewed showing no annual performance evaluation |
| CNA10 | Certified Nursing Assistant | Personnel file reviewed showing no annual performance evaluation |
| Director of Nursing | Director of Nursing | Interviewed regarding annual performance evaluations |
| Administrator | Administrator | Interviewed regarding annual performance evaluations |
Inspection Report
Abbreviated Survey
Census: 138
Deficiencies: 0
May 2, 2025
Visit Reason
An Abbreviated Survey was conducted to assess the facility's compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies issued related to the cited regulations.
Report Facts
Sample Size: 11
Supplemental Resident: 1
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
May 1, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving a staff member suspected of arson after a fire occurred in the room of two residents on 05/01/2024. The visit aimed to investigate the facility's failure to provide a safe environment and adequate supervision to prevent accidents.
Findings
The facility failed to protect residents when a Social Services Assistant (SSA) threatened a resident and was subsequently arrested for arson after a fire in the residents' room. The facility lacked adequate staff monitoring and failed to prevent immediate jeopardy to resident health and safety. The fire was extinguished with no injuries, but the incident revealed serious safety and supervision deficiencies.
Complaint Details
The complaint investigation revealed that on 05/01/2024, the SSA threatened Resident 14 and was later arrested for arson after a fire occurred in the room shared by Resident 14 and Resident 466. The SSA exhibited suspicious behavior prior to the fire, including making threatening statements and entering the residents' room shortly before the fire alarm sounded. The facility was found non-compliant with requirements to ensure resident safety and supervision.
Severity Breakdown
Immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Immediate jeopardy |
Report Facts
Residents affected: 24
Fire incident time: 1657
SSA time in room: 58
BIMS score R14: 15
BIMS score R466: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Witnessed SSA threatening Resident 14 and noted suspicious behavior prior to fire |
| Social Services Assistant | Social Services Assistant | Staff member who threatened Resident 14 and was arrested for arson |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Reported SSA's profane behavior towards Resident 14 |
| Certified Medication Technician 3 | Certified Medication Technician | Reported SSA's comment about Resident 14 after the fire |
| Administrator in Training | Administrator in Training | Provided information about SSA's complaints regarding Resident 14 |
| Administrator | Administrator | Discussed facility responsibility and staff education after the incident |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 1
Apr 20, 2024
Visit Reason
The inspection was conducted following two separate fire incidents in the room of a resident (R57) who was found to have smoking materials despite the facility's non-smoking policy. The visit aimed to investigate the facility's compliance with safety and smoking policies and the circumstances leading to the fires.
Findings
The facility failed to provide a safe environment by not adequately assessing and securing smoking materials for a resident who caused two fires. The resident was not assessed for smoking upon admission as required, and lighters were accessible despite the non-smoking policy. Multiple residents were potentially affected, and the facility lacked a formal method to track smoking materials. Staff interviews revealed inconsistent enforcement and knowledge of smoking policies.
Complaint Details
The investigation was complaint-related due to two fires caused by Resident 57 who was found with cigarettes and a lighter despite the facility's non-smoking policy. The resident denied smoking but was involved in two fires on 04/15/2024 and 04/16/2024. The complaint was substantiated by observations, interviews, and review of policies and records.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a safe environment by not assessing smoking status and securing incendiary devices, leading to two fires caused by a resident possessing cigarettes and a lighter. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents evacuated: 16
Total census: 150
Residents potentially affected: 64
BIMS score: 0
BIMS score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 16 | Licensed Practical Nurse | Stated smoking assessment was part of admission assessment and no recurrent assessments were done. |
| Admissions Director | Admissions Director | Interviewed regarding smoking assessment timing and admission process. |
| Social Services Assistant | Social Services Assistant | Provided detailed account of fire incidents and resident behaviors. |
| Unit Manager | Unit Manager | Involved in fire response and investigation of smoking materials. |
| Certified Nursing Assistant 37 | Certified Nursing Assistant | Reported knowledge of residents smoking and confiscation of lighters. |
| Main Entrance Receptionist 1 | Receptionist | Described securing smoking materials in locked box and changes in procedure. |
| Main Entrance Receptionist 2 | Receptionist | Described process for residents signing in/out smoking materials. |
| Social Services Director | Social Services Director | Discussed facility smoking policies and requirements for residents. |
| Certified Nursing Assistant 17 | Certified Nursing Assistant | Discussed orientation process and welcome packet. |
| Certified Nursing Assistant 22 | Certified Nursing Assistant | Discussed lack of awareness of welcome process and prohibited items list. |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed challenges with smoking compliance after resident transfers and tracking methods. |
| Director of Nursing | Director of Nursing | Discussed non-smoking campus policy, resident rights, and supervision practices. |
| Administrator | Administrator | Discussed facility policies on smoking materials, resident rights, and monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Feb 6, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding medication administration errors, resident abuse, elopement, and other care concerns at the facility.
Findings
The facility failed to ensure proper medication administration, including allowing residents to self-administer without orders, failed to prevent physical abuse of a resident, failed to prevent elopement of a cognitively impaired resident, failed to properly monitor tube feeding administration, and failed to maintain sanitary food preparation and storage practices. The facility also failed to implement policies and procedures effectively, including timely notification of missing residents and proper oversight by administration.
Complaint Details
The complaint investigation was substantiated with findings of medication administration errors, physical abuse, elopement, inadequate tube feeding monitoring, unsanitary food handling, and administrative failures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure Medication Aide did not allow residents to self-administer medications without physician orders and interdisciplinary assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from physical abuse by staff, resulting in termination of involved employees. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent elopement of a cognitively impaired resident who left the facility and was found on a highway after 18 hours. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure staff administered tube feeding formula at the prescribed rate and accurately monitored the amount infused each shift. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, and served in a sanitary manner, including failure to follow hand hygiene, cross-contamination prevention, jewelry policies, and proper labeling and dating of food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the facility administrator took proper measures to ensure resident safety related to elopement and missing resident protocols. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure the governing body implemented policies for managing and operating the facility, including oversight of resident safety and elopement prevention. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 152
Tube feeding formula volume: 1333
Tube feeding formula volume: 1583
Tube feeding formula volume: 981
Temperature: 43
Blood glucose: 250
BIMS score: 15
BIMS score: 14
BIMS score: 3
BIMS score: 10
BIMS score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA #58 | Medication Aide | Named in medication self-administration deficiency |
| CNA #74 | Certified Nursing Assistant | Named in physical abuse allegation and termination |
| CNA #75 | Certified Nursing Assistant | Named in physical abuse allegation and termination |
| CNA #76 | Certified Nursing Assistant | Named in physical abuse allegation and termination |
| LPN #2 | Licensed Practical Nurse | Named in elopement incident and progress notes |
| RN #3 | Registered Nurse | Named in elopement incident and search efforts |
| Administrator #54 | Administrator | Named in elopement incident and administrative failures |
| DON #27 | Director of Nursing | Named in elopement incident and administrative failures |
| RDCS | Regional Director of Clinical Services | Named in abuse investigation and elopement oversight |
| RVPO | Regional Vice President of Operations | Named in elopement incident and policy statements |
| NP #38 | Nurse Practitioner | Named in elopement incident and clinical oversight |
| LPN #16 | Licensed Practical Nurse | Named in tube feeding monitoring deficiency |
| Dietary Aide #8 | Dietary Aide | Named in food handling deficiency |
| Dietary Director | Dietary Director | Named in food handling deficiency |
| [NAME] #24 | Assistant Dietary Manager | Named in food handling deficiency |
Inspection Report
Routine
Deficiencies: 7
Feb 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident care, respiratory care, food safety, and facility safety.
Findings
The facility was found deficient in multiple areas including improper medication administration practices, failure to ensure proper placement of medical equipment, discrepancies in resident code status documentation, inadequate supervision to prevent resident elopement, improper respiratory care, unsanitary food handling and storage practices, and failure to maintain dumpsters in a sanitary condition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure Medication Aide did not allow residents to self-administer medications without physician orders and interdisciplinary assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper placement of a stability boot for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident's code status was accurately reflected in physician orders and care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent elopement of a resident, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide proper respiratory care including maintenance and storage of tracheostomy and CPAP/BiPAP equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, and served in a sanitary manner, including improper hand hygiene, cross-contamination, and improper labeling and dating of food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dumpsters were closed and the area around them was free of trash to prevent vermin and pest attraction. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 5
Residents affected: 152
Residents affected: 155
Elopement risk score: 2
BIMS score: 15
BIMS score: 14
BIMS score: 10
BIMS score: 10
BIMS score: 0
Temperature: 43
Blood glucose: 250
Oxygen flow rate: 2.5
Oxygen flow rate: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA #58 | Medication Aide | Named in medication self-administration deficiency |
| LPN #2 | Licensed Practical Nurse | Charge nurse involved in elopement event documentation |
| RN #3 | Registered Nurse | Weekend supervisor involved in elopement event |
| NP #38 | Nurse Practitioner | Involved in respiratory care and code status findings |
| LPN #45 | Licensed Practical Nurse | Involved in tracheostomy care observations |
| LPN #39 | Licensed Practical Nurse | Involved in respiratory care observations |
| CNA #12 | Certified Nursing Assistant | Involved in respiratory care observations |
| Dietary Aide #8 | Dietary Aide | Observed and interviewed regarding food handling deficiencies |
| [NAME] #7 | Dietary Staff | Observed and interviewed regarding food handling deficiencies |
| [NAME] #24 | Assistant Dietary Manager | Interviewed regarding food handling and dumpster maintenance |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies and facility policies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies and facility policies |
| Maintenance Director | Maintenance Director | Interviewed regarding dumpster maintenance responsibility |
Inspection Report
Routine
Census: 122
Deficiencies: 4
Jan 31, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, food sanitation, clinical record maintenance, infection prevention and control, and wound care at Valhalla Post Acute facility.
Findings
The facility was found deficient in providing safe respiratory care, maintaining sanitary food preparation and storage, documenting wound care accurately, and implementing effective infection prevention and control practices. Specific issues included improper oxygen equipment handling, unsanitary kitchen conditions, incomplete wound documentation, and inadequate disposal of contaminated wound dressings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide safe and appropriate respiratory care including labeling and infection control for oxygen equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was stored, prepared, and distributed under sanitary conditions including improper hair restraints, contaminated food handling, unlabeled food storage, and dirty dishware. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a complete and accurate clinical record for wound care including lack of wound measurements and documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an effective infection prevention and control program including improper disposal of heavily soiled wound dressings and contaminated materials. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving meals: 122
Residents in sample: 45
Residents affected: 1
Residents affected: 1
Stage IV pressure ulcers: 6
Stage IV pressure ulcers: 1
Wounds assessed: 8
Oxygen liters: 5
Oxygen inhaled medication frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #14 | LPN | Named in respiratory care and infection control deficiencies related to oxygen equipment and wound care |
| Licensed Practical Nurse #15 | LPN | Named in respiratory care and infection control deficiencies related to oxygen equipment and wound care |
| Licensed Practical Nurse #6 | LPN | Named in respiratory care and infection control deficiencies related to oxygen equipment and wound care |
| Assistant Director of Nursing | ADON | Named in wound care documentation and infection control deficiencies |
| Director of Nursing | DON | Named in respiratory care, wound care, and infection control deficiencies |
| Administrator | Administrator | Named in respiratory care, wound care, and infection control deficiencies |
| Sanitation worker | Named in food sanitation deficiency | |
| Dietary Manager | DM | Named in food sanitation deficiency |
| Dietary Aide #1 | DA | Named in food sanitation deficiency |
| Staff Development Coordinator | SDC | Named in infection control deficiency |
| Quality Assurance nurse | QA nurse | Named in infection control deficiency |
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