Inspection Reports for
Valhalla Post Acute

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.

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.

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.

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.

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.

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.

The complaint investigation was substantiated with findings of medication administration errors, physical abuse, elopement, inadequate tube feeding monitoring, unsanitary food handling, and administrative failures.

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.

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.

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.