Valhalla Post Acute

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteAMENDEDBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. Subsequently, on 05/01/2024 the SSA was arrested for suspicion of arson after a fire occurred in the room of R14 and R466. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteThe facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows: 1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021. 2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The police found Resident #112 along a highway (unknown location) on 05/10/2021 at approximately 10:00 AM, approximately eighteen (18) hours after the resident left the facility. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.