Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valhalla Post Acute during CMS and state inspections, most recent first.
A facility failed to provide palatable food at an appetizing temperature. A test tray was bland and lacked flavor, and multiple residents reported poor taste, cold meals, missing items, limited variety, and not receiving ordered foods. Staff also acknowledged complaints about cold food and food not tasting well, while the Dietary Manager and Administrator were unaware of the concerns.
A facility failed to provide a safe environment, resulting in a staff member being arrested for arson after a fire in a resident's room. The staff member had previously expressed frustration and made threats towards a resident. Despite warning signs, no formal monitoring was in place, and the incident highlighted significant lapses in supervision and safety protocols.
The facility failed to enforce its smoking policy and properly assess and monitor residents for smoking risks, leading to two separate fire incidents involving a resident. Staff interviews and observations revealed inconsistent enforcement of the smoking policy, with some residents keeping lighters and cigarettes in their rooms. The facility only began securing smoking materials in a locked box after the survey and fire incidents.
A resident with moderately impaired cognition left the facility without notifying staff and was found on the side of a highway after being exposed to cold weather overnight. The facility failed to notify the police until approximately 18 hours later, contrary to their policy, and did not follow their emergency procedure for a missing resident.
A resident with moderate cognitive impairment left the facility and was missing for approximately 18 hours. The facility did not follow its missing resident protocol, concluding the resident left against medical advice (AMA) and took no further action to locate them. The police found the resident along a highway the next day, and the resident was transported to a local hospital for cold exposure.
A resident with moderately impaired cognition left the facility without notifying staff, and the facility failed to follow its emergency procedures to locate the resident. The resident was found the next day on the side of a highway and was transported to a hospital for cold exposure. Inconsistencies in staff documentation and delayed notification to the police contributed to the incident.
The facility failed to ensure that three dumpsters were properly closed and the surrounding area was free of trash, potentially attracting vermin and pests. Observations revealed open dumpsters and littered trash, including gloves, cigarette butts, and food packets. Interviews with staff indicated confusion over who was responsible for maintaining the dumpsters.
The facility failed to ensure sanitary food storage, preparation, and service for all residents. Staff did not follow proper hand hygiene, cross-contamination prevention, and jewelry policies. Additionally, nourishment room refrigerators contained undated and expired food items.
The facility failed to ensure that a Medication Aide did not allow two residents to self-administer their medications without proper physician orders and interdisciplinary team assessments. Both residents, who had histories of COPD and dementia, were observed self-administering medications without the necessary orders, and the staff confirmed the error.
A resident with severe cognitive impairment was subjected to physical abuse by CNAs, including being forcefully rolled and smacked on the leg. Video footage confirmed the abuse, and the involved staff were terminated following an investigation.
A resident with a feeding tube did not receive the prescribed amount of tube feeding formula due to staff failing to monitor and record the amount infused each shift. Despite orders to document and clear the tube feeding pump, staff inconsistently recorded the amounts, leading to the resident not receiving the recommended daily caloric intake.
The facility failed to ensure proper placement of a stability boot for a resident with severe cognitive impairment and fractures in the right leg. The boot was incorrectly placed on the left foot, and staff interviews revealed confusion about responsibility for checking the boot's placement and skin integrity.
A resident with a Do Not Resuscitate (DNR) order had conflicting documentation in their medical records, indicating full code status. Interviews confirmed the resident's DNR status, and the Director of Nursing acknowledged the importance of consistent documentation.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies such as unavailable tracheostomy supplies, improper maintenance of CPAP/BiPAP machines, and inadequate cleaning and storage of nebulizer equipment. Staff interviews revealed a lack of knowledge and adherence to care procedures.
Food Was Bland, Cold, and Not Consistently Served as Ordered
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Review of the facility’s Food and Nutrition Services policy showed that staff were to make reasonable efforts to accommodate resident choices and preferences, inspect trays for correct meals, ensure food was served at safe and appetizing temperatures, report incorrect or unpalatable meals, and provide nourishing snacks and a variety of foods. During a test tray observation during lunch meal preparation, the food tasted bland and was absent of flavor. Resident interviews reflected widespread dissatisfaction with meal quality and accuracy. One resident reported intolerable food, including burned hotdogs, junk food snacks, missing yogurt, and limited meat variety. Other residents stated the facility failed to provide ordered food, the food was not very good, did not taste good, was meh, so-so, terrible, or sometimes cold. One resident said residents no longer get choices, and another stated, “I never get what I ask for.” Staff interviews confirmed complaints about cold food and food not tasting well, while the Dietary Manager stated she had not received complaints and could not recall residents receiving meals they did not prefer, missing food, or complaining about cold food. The Administrator stated he was unaware of resident concerns regarding the food provided.
Failure to Provide Safe Environment Leads to Arson Incident
Penalty
Summary
The facility failed to provide a safe environment for residents, leading to a serious incident involving a staff member. On 05/01/2024, a Social Services Assistant (SSA) was arrested under suspicion of arson after a fire occurred in the room of two residents. Prior to the fire, the SSA had expressed frustration and threatened one of the residents. The SSA was observed entering and exiting the room shortly before the fire alarm sounded, and video footage confirmed the SSA's presence in the room for approximately 58 seconds before the fire started. The fire was extinguished, and one resident, who required total assistance for mobility, was safely evacuated without injury. The facility's policies on safety and supervision, as well as accidents and incidents, were not effectively implemented. The SSA's behavior had been noted by multiple staff members, including making threatening statements and inquiring about the presence of cameras in residents' rooms. Despite these warning signs, no formal monitoring of staff behavior was in place at the time of the incident. The facility's investigation revealed that the SSA had been frustrated with one of the residents for repeatedly asking to be taken to a store, which may have contributed to the SSA's actions. Interviews with staff and residents highlighted the SSA's inappropriate behavior and the lack of effective supervision. The Administrator acknowledged the facility's responsibility to keep residents safe but admitted that there was no formal staff monitoring system in place before the incident. The facility has since provided education to all staff regarding awareness of surroundings and reporting suspicious behaviors, but these actions were taken after the incident occurred.
Failure to Enforce Smoking Policy Leads to Fires
Penalty
Summary
The facility failed to provide a safe environment for residents by not adequately assessing and managing smoking risks, leading to two separate fire incidents involving a resident. The facility's policy stated that it was a non-smoking environment and that smoking materials, including lighters, were prohibited. However, the facility did not complete a smoking assessment for the resident upon admission, and the resident was found in possession of cigarettes and a lighter after both fire incidents. The first fire occurred in the resident's bathroom, and the second fire occurred in the resident's closet, resulting in the evacuation of the unit and involvement of the fire department. Interviews with staff revealed a lack of awareness and inconsistent enforcement of the facility's smoking policy. The Admissions Director and LPN stated that smoking assessments were part of the admission process, but no recurrent assessments were conducted. The Social Services Assistant and Unit Manager confirmed that they found smoking materials in the resident's room after the first fire and placed the resident on 15-minute checks. Despite this, the resident was involved in a second fire the following day. Other residents and staff indicated that smoking materials were not consistently confiscated or stored securely, and some residents admitted to keeping lighters and cigarettes in their rooms. The facility's failure to enforce its smoking policy and properly assess and monitor residents for smoking risks led to significant safety hazards. Staff interviews and observations indicated that the facility only began to secure smoking materials in a locked box after the survey and fire incidents. The Director of Nursing and Administrator acknowledged the challenges in preventing residents from obtaining smoking materials off-property and the limitations in searching residents without their permission. The facility's inconsistent practices and lack of a formal method to track smoking materials contributed to the deficiency and the occurrence of the fires.
Resident Elopement and Delayed Police Notification
Penalty
Summary
The facility failed to ensure the safety of a resident with moderately impaired cognition, who left the facility without notifying staff. The resident, who required supervision and assistance with activities of daily living, was found on the side of a highway after being exposed to cold weather overnight. The facility did not notify the police until approximately 18 hours after the resident left, contrary to their policy which required police notification if a resident was not found within ten minutes. The resident's care plan indicated the need for supervision and assistance, but there was no documented evidence that the facility planned for the resident to leave the facility unsupervised. Staff members, including the charge nurse and the Director of Nursing, were aware of the resident's absence but did not follow the facility's emergency procedure for a missing resident. The Administrator also failed to take appropriate action, including notifying the police promptly. Interviews with staff and the resident's responsible party revealed discrepancies in the documentation and actions taken by the facility. The resident's family was asked to call the police, and the Administrator attempted to have them sign a waiver indicating the resident left against medical advice, which they refused. The facility's failure to follow their own policies and procedures put the resident at risk of serious harm.
Failure to Implement Missing Resident Protocol
Penalty
Summary
The facility's governing body failed to ensure the implementation of policies regarding the management and operation of the facility. On 05/09/2021, a resident with moderate cognitive impairment left the facility and was missing for approximately 18 hours. The facility did not follow its missing resident protocol, which required initiating a thorough search and notifying the police within 10 minutes if the resident was not found. Instead, the facility concluded that the resident left against medical advice (AMA) and took no further action to locate the resident. The police eventually found the resident along a highway the next day, and the resident was transported to a local hospital for cold exposure. The resident, who had diagnoses including acute kidney failure, chronic kidney failure, stroke, muscle weakness, type 2 diabetes, cognitive communication deficit, major depressive disorder, and heart failure, required extensive assistance with daily activities and was assessed to have moderate cognitive impairment. The facility's records indicated that the resident was not steady and needed staff assistance for transfers and mobility. Despite this, the facility did not have a documented plan for the resident to leave the facility unsupervised. The facility's failure to follow its own policies and protocols for a missing resident led to a situation where the resident was exposed to potential harm. The governing body was aware of the incident but did not take appropriate action to ensure the resident's safety. This non-compliance with the requirements of participation caused or was likely to cause serious injury, harm, impairment, or death to the resident, resulting in the identification of Immediate Jeopardy and Substandard Quality of Care at the facility.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with moderately impaired cognition. The resident, who required extensive assistance with activities of daily living and had a history of cognitive impairment, left the facility without notifying staff. The facility's policy required staff to initiate a thorough search and contact the police if a resident was not found within ten minutes, but this protocol was not followed. The resident was found the next day on the side of a highway and was transported to a hospital for cold exposure. The facility's documentation and staff interviews revealed inconsistencies and inaccuracies in the reporting of the incident. The charge nurse's progress notes inaccurately stated that the resident had informed her of their intention to go to the store and that she had seen the resident leave through the double doors. However, the charge nurse later clarified that she did not receive any such notification from the resident and did not witness the resident leaving. Additionally, the facility did not notify the police until approximately 18 hours after the resident was discovered missing. Interviews with the resident and their responsible party indicated that the resident did not plan to leave the facility permanently and had not informed anyone of their intention to go to the store. The responsible party also stated that the resident was confused and not capable of making a decision to leave against medical advice. The facility's failure to follow its own emergency procedures and the discrepancies in staff documentation and actions contributed to the resident's elopement and subsequent exposure to cold weather.
Improper Dumpster Maintenance and Trash Disposal
Penalty
Summary
The facility failed to ensure that three dumpsters were properly closed and the surrounding area was free of trash, which could potentially attract vermin and pests. Observations over several days revealed that the dumpsters were consistently left open, with trash and debris littered around the area. Items found included gloves, cigarette butts, a bottle of clinical cleanser, pieces of wood, cardboard, plastic, a soda can, a creamer packet, jam and peanut butter packets, and a plastic bag. These conditions were observed despite the dumpsters being labeled for specific types of waste, such as cardboard only, which were not adhered to as general trash was also found in them. Interviews with various staff members, including the Assistant Dietary Manager, Dietary Director, Maintenance Director, Director of Nursing (DON), and the Administrator, revealed confusion and lack of clarity regarding who was responsible for maintaining the dumpsters. The Assistant Dietary Manager and Dietary Director stated that the dietary staff were responsible, while the Maintenance Director believed it should be the maintenance department's responsibility. The DON was unaware of who was responsible, and the Administrator confirmed that although the dietary department was primarily responsible, maintenance and housekeeping staff also frequented the dumpsters. This lack of clear responsibility contributed to the ongoing issue of improperly maintained dumpsters and surrounding areas.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure staff stored, prepared, and served foods in a sanitary manner for all 152 residents. During meal service, a dietary aide touched her forehead with a gloved hand and continued serving trays without changing gloves or washing her hands. This action was against the facility's policy, which mandates changing gloves and washing hands between tasks. Both the dietary aide and the Dietary Director confirmed that the expected practice was not followed. Additionally, a cook used a knife with raw meat particles to slice cooked meatloaf without cleaning or sanitizing it. This violated the facility's policy on preventing cross-contamination. The cook and the Dietary Director acknowledged that equipment should be sanitized after handling raw meat to avoid cross-contamination. The facility also failed to ensure that personal jewelry did not come into contact with food. A cook was observed handling meatloaf while wearing a bracelet, which touched the food. This was against the facility's policy, which allows only minimal jewelry and requires it to be covered with gloves. Furthermore, multiple nourishment room refrigerators contained undated and expired food items, contrary to the facility's policy requiring proper labeling and timely disposal of such items. Interviews with dietary staff and the Director of Nursing confirmed that these practices were not adhered to, leading to potential food safety issues.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a Medication Aide (MA) did not allow two residents to self-administer their medications without proper physician orders and interdisciplinary team assessments. Resident #96, who had a history of chronic obstructive pulmonary disease (COPD) and unspecified dementia, was observed self-administering Flonase nasal suspension without a physician's order. The resident's Quarterly Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, showing cognitive intactness, but there was no order for self-administration of medications. MA #58 confirmed that the resident administered five sprays in the right nostril and four sprays in the left nostril, exceeding the prescribed dosage of two sprays in each nostril once a day. Similarly, Resident #18, who also had a history of COPD and unspecified dementia, was observed self-administering an Incruse inhaler without a physician's order. The resident's Annual MDS indicated a BIMS score of 14, showing cognitive intactness, but there was no order for self-administration of medications. MA #58 confirmed that the resident self-administered one puff of the inhaler. Both the Administrator and the Director of Nursing stated that they expected staff to follow physician's orders and facility policies, acknowledging that allowing the residents to self-administer their medications was an error.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse. The incident involved a resident with severe cognitive impairment who required extensive assistance with daily activities. The resident's Power of Attorney (POA) reported that a Certified Nursing Assistant (CNA) smacked the resident's legs while providing care, another CNA ate food from the resident's meal tray, and a third CNA handled the resident roughly. Video footage confirmed that a male staff member forcefully rolled the resident to the point where the resident's leg hung off the bed while the resident yelled for help, and a female staff member laughed. Another video showed a female staff member smacking the resident's leg three times when the resident resisted care. The facility's initial report indicated that an investigation was started, the appropriate agencies were notified, and the involved staff were placed on administrative leave. The final report revealed that a nurse conducted a full body assessment of the resident and found no areas of discoloration or other concerns. Psychosocial visits were conducted, and no distress or concerns were noted. Interviews with the involved CNAs were attempted, but only one CNA responded, denying any inappropriate interactions. The facility terminated the employment of the involved CNAs based on the investigation findings. Interviews with the facility's administration and regional staff confirmed that the incident was reported and investigated promptly. The Regional Vice President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) were involved in guiding the investigation. The RDCS ensured the resident's safety and conducted a skin assessment. The staff members were terminated for failing to meet the facility's code of conduct and for not participating in the investigation.
Failure to Administer Tube Feeding Formula as Prescribed
Penalty
Summary
The facility failed to ensure that staff administered tube feeding formula at the rate prescribed by the physician for Resident #135. The resident, who had a feeding tube due to conditions such as hemiplegia, hemiparesis, and dysphagia following a stroke, was supposed to receive Jevity 1.2 at 70 ml/hr continuously. However, staff did not consistently monitor or record the amount of tube feeding formula infused each shift, leading to the resident not receiving the recommended daily caloric intake as prescribed by the Registered Dietitian (RD) and ordered by the physician. Documentation revealed that staff did not begin recording the amount of tube feeding formula infused each shift until 12/28/2023, despite an order dated 12/04/2023 directing them to do so. Prior to this date, staff only initialed the Medication Administration Record (MAR) or referred to the resident's progress notes, which showed inconsistent and insufficient amounts of tube feeding formula being administered. Specific dates were noted where the resident did not receive the minimum required 1,333 ml of tube feeding formula daily, as recommended by the RD. Interviews with staff, including an LPN, the RD, a Nurse Practitioner (NP), and the Director of Nursing (DON), confirmed that the tube feeding formula was not administered correctly. The LPN admitted to estimating the amount of formula infused, while the RD and NP highlighted the importance of accurate monitoring to prevent negative outcomes. The DON and Administrator both emphasized the expectation that staff follow the facility's policies and physician's orders, which was not done in this case.
Improper Placement of Stability Boot
Penalty
Summary
The facility failed to ensure proper placement of a stability boot for Resident #68, who had severe cognitive impairment and required extensive assistance with personal hygiene. The resident had a history of fractures in the right fibula and tibia, and an order was in place to remove the boot every shift to check skin integrity. However, during an observation, it was noted that the resident's boot was incorrectly placed on the left foot instead of the right. This error was immediately identified by the CNAs, who then corrected the placement after transferring the resident back to bed. Interviews with staff revealed a lack of clarity regarding responsibility for ensuring the correct application of durable medical equipment (DME). The Nurse Practitioner confirmed that the boot was for stabilization and should always be on the right foot. The LPNs interviewed indicated that it was the nurses' responsibility to check the boot for proper placement and skin integrity, not the CNAs. The Director of Nursing reiterated that nurses needed to check DME every shift for skin integrity and placement, highlighting a gap in adherence to this protocol.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in their medical records. Resident #463, who had diagnoses including metabolic encephalopathy, cognitive communication deficit, and unspecified dementia, was admitted with a Do Not Resuscitate (DNR) order. However, a review of the resident's Order Summary Report revealed an order for full code status, which contradicted the DNR order. This discrepancy was also found in the resident's care plan, which indicated full code status despite the DNR order. Interviews with the resident's Power of Attorney (POA) confirmed that the resident's code status was DNR. The Director of Nursing (DON) acknowledged that there should not be any discrepancies in the resident's code status and emphasized the importance of consistent documentation to honor the resident's wishes in an emergency. The Administrator deferred all questions regarding the resident's code status to the nursing staff.
Deficiencies in Respiratory Care for Three Residents
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to several deficiencies. For Resident #62, the facility did not ensure the availability of necessary tracheostomy supplies, including a properly sized tracheostomy tube and a clean, functional suction machine. Observations revealed that the suction machine was dusty and lacked tubing, and there was no supplemental oxygen available in the room. Interviews with staff indicated a lack of knowledge about the resident's tracheostomy tube size and proper care procedures, and the Director of Nursing admitted that the tracheostomy tube size had been missing from the physician's order for an extended period. For Resident #127, the facility failed to maintain and properly use the resident's CPAP/BiPAP machine and oxygen concentrator. Observations showed that the oxygen concentrator was set incorrectly, and the CPAP/BiPAP machine was found covered in dust and not in use, despite documentation indicating otherwise. Staff interviews revealed confusion about the resident's respiratory care orders and improper maintenance of the equipment, including outdated nebulizer tubing and a lack of proper cleaning and storage. Resident #57's respiratory care was also deficient, as the nebulizer machine and mask were not properly cleaned or stored. Observations over several days showed debris and fluid in the mask and medication chamber, and the equipment was not stored in a plastic bag as required. Staff interviews confirmed that the nebulizer equipment was not being changed weekly or stored correctly, and the Director of Nursing acknowledged the failure to follow proper procedures for respiratory care equipment maintenance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Springs Health Campus | 4.1 mi | ★★★★★ | 3 | 0 |
| Jeffersontown Rehabilitation | 5 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of East Louisville | 5.6 mi | ★★★★★ | 0 | 0 |
| The Willows At Springhurst | 5.7 mi | ★★★★★ | 4 | 0 |
| The Springs At Stony Brook | 6.3 mi | ★★★★★ | 0 | 0 |
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