Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Valley Hill Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage and handling, including unlabeled and undated food items, improper storage of opened products, food stored at incorrect temperatures, spoiled produce in the cooler, food stored directly on the floor, and a dented can in dry storage. The Dietary Manager and Administrator confirmed that these practices did not meet professional standards for food service safety.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and a history of weight fluctuations did not receive physician-ordered nutritional supplements with meals on multiple occasions. Despite clear orders for a nutritional shake and frozen treat, direct observations showed these items were missing from meal trays, and staff interviews confirmed supplements should have been provided as listed on meal tickets.
A resident with severe cognitive impairment and a physician's order for a mechanical soft diet was served whole boneless chicken breasts, which did not comply with the prescribed mechanically altered diet. The error was discovered before the resident ate, and staff interviews confirmed the meal did not meet the required diet texture.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident's belongings or money were wrongfully used due to the facility's failure to provide adequate protection, resulting in a violation of the resident's rights.
The facility failed to prevent two residents with known elopement risks from exiting the premises unsupervised. One resident was found off property by law enforcement, and another was found in the facility parking lot. Both incidents involved lapses in monitoring and issues with elopement alarm systems.
An agency nurse failed to properly clean and disinfect a shared glucometer between use on two residents due to a lack of training and verification of competency. The nurse was unaware of the facility's procedures and the manufacturer's guidelines for the EPA-approved disinfectant wipe's contact time. Interviews revealed gaps in the orientation process for new and agency staff, contributing to the deficiency.
The facility staff failed to disinfect a shared glucometer between residents according to the manufacturer's guidelines, leading to potential exposure to bloodborne pathogens. An agency nurse used the glucometer on two residents without adhering to the required contact time with the disinfectant wipe, highlighting a significant gap in infection control practices and staff training.
The facility's QAA committee failed to maintain and monitor procedures in Infection Control, Accident Prevention, and Food Safety. Deficiencies included improper disinfection of a glucometer, failure to prevent unsupervised exits by cognitively impaired residents, and expired food in a walk-in cooler. Despite monthly QAA meetings, the facility continued to exhibit these deficiencies over multiple surveys.
The facility failed to remove expired medications from two of four locked medication carts. Expired calcium carbide tablets and Omeprazole capsules were found in the B hall and C hall medication carts, respectively. The DON and Unit Manager acknowledged the oversight and confirmed that the expired medications should have been removed.
The facility failed to discard expired food in the walk-in cooler, including shredded cheese, chili, and pureed fruit. Despite daily checks by the Cook/Assistant and Dietary Manager, these items were overlooked. The Administrator confirmed the expectation for all expired food to be removed.
A resident with heart failure, diabetes, and chronic pain was not assessed for self-administration of medications, leading to medication being left unattended at the bedside. The resident was unaware of the medication's presence, and staff confirmed that proper assessment and administration protocols were not followed.
A facility failed to ensure accurate code status information for a resident, resulting in conflicting documentation between the paper and electronic medical records. Interviews revealed a lack of a specific process to ensure consistency, with the Unit Manager, DON, and Social Worker acknowledging the need for clarification and regular checks.
Deficient Food Storage, Labeling, and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and handling within the facility's kitchen, dry storage, reach-in cooler, and nourishment room. In the kitchen, bins containing white powder-like substances, as well as boxes of baking soda and cornstarch, were found opened, unlabeled, and undated. An opened bottle of lemon juice labeled for refrigeration was stored at room temperature and was also unlabeled and undated. The Dietary Manager confirmed these items should have been labeled, dated, and properly stored. In the reach-in cooler, an unopened bag of chopped cabbage with multiple brown spots and no expiration or best-by date was found, indicating spoilage. The Dietary Manager acknowledged that food showing signs of spoilage should be discarded and was unsure why the cabbage was present. In the dry storage room, several large bags and boxes of food, including flour, vegetable oil, corn cereal, and rice cereal, were stored directly on the floor. Additionally, a bin of undated graham crackers and a dented can of cream of chicken soup were found on the shelves. The Dietary Manager stated that food should not be stored on the floor, dented cans should be removed, and all items should be labeled and dated. In the nourishment room, an opened and undated box of nutritional supplement was found in the freezer. The Dietary Manager reported that nourishment refrigerators and freezers are cleaned daily but could not explain the presence of the undated supplement. The Administrator confirmed expectations for proper labeling, dating, and storage of all food items throughout the facility.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to follow physician orders to provide prescribed nutritional supplements to a resident with non-Alzheimer's dementia who was on a weight-gain regimen. The resident had a history of weight fluctuations and was considered at increased nutrition and hydration risk, requiring a mechanically altered diet. Physician orders specified a 4-ounce nutritional shake three times daily with meals and a frozen nutritional treat twice daily. Despite these orders, direct observations on two separate days showed that the resident did not receive the ordered supplements with her lunch meal. Meal tickets indicated the supplements were to be provided, but they were absent from the meal trays. Interviews with the Dietary Manager and Registered Dietitian confirmed that supplements should have been provided as ordered. The Dietary Manager was unable to explain why the supplements were missing, and the Registered Dietitian noted that even though the order for the frozen nutritional treat was discontinued on one of the days, the meal tray tickets had not been updated in the dietary computer system. Staff were still expected to provide items as listed on the tray tickets. The responsible dietary aide was unavailable for interview, and the administrator stated that all residents should receive nutritional supplements as ordered.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia was admitted to the facility and had a physician's order for a mechanical soft diet. The resident's care plan identified an increased nutrition and hydration risk related to the need for a mechanically altered diet, with interventions specifying that the diet and supplements should be provided as ordered. During a lunch meal observation, the resident was served two whole boneless chicken breasts, which did not meet the requirements of a mechanical soft diet as ordered by the physician and indicated on the meal ticket. The error was identified before the resident began eating, and the meal was removed after confirmation by the administrator that whole chicken breasts were not mechanically soft. Staff interviews revealed that the nurse aide who set up the tray did not notice the discrepancy, and the dietary manager was unsure why the correct meal was not provided. The registered dietitian and speech therapist both confirmed that the resident should have received the mechanically altered diet as ordered, and that whole chicken breasts were not appropriate for this diet texture.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Wrongful Use of Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by facility staff led to the resident's belongings or money being wrongfully used, violating the resident's rights and facility policy. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents from exiting the facility unsupervised and without staff knowledge. Resident #127, who had a court-appointed guardian and required supervision due to poor safety awareness, was last seen in the facility at approximately 10:30 AM. Despite being monitored, Resident #127 was found missing at 12:00 PM, leading to a facility-wide search. He was eventually located off the facility property by law enforcement at 1:10 PM. The resident had a history of elopement attempts and wore an elopement alarm monitoring device, which was found on the floor of his room, indicating it had been removed. Staff interviews revealed that Resident #127 had been verbalizing a desire to leave and had been observed near exit doors prior to his elopement. Resident #67, who had impaired cognition and a history of exit-seeking behavior, was last observed in the facility at approximately 7:10 AM. Shortly after, at around 7:15 AM, staff found Resident #67 outside in the facility parking lot, squatted between two parked cars. The resident was escorted back into the facility by staff. Resident #67 had an elopement alarm monitoring device, but it was noted that the door did not alarm due to the resident entering the code and a malfunction of the elopement alarm monitoring device sensor. Staff progress notes indicated that Resident #67 had been exit-seeking since early morning and had been monitored by staff, but still managed to exit the building. Both incidents highlight the facility's failure to adequately supervise and prevent residents with known elopement risks from leaving the premises unsupervised. The facility's investigation and staff interviews revealed lapses in monitoring and potential issues with the elopement alarm systems. These deficiencies put the residents at risk of serious injury, harm, or death while they were outside the facility unsupervised.
Failure to Train and Verify Competency in Glucometer Disinfection
Penalty
Summary
The facility failed to train and verify the competency of an agency nurse on the proper cleaning and disinfecting procedures for a shared glucometer. This deficiency was observed when the agency nurse did not clean and disinfect the glucometer between its use on two residents. The nurse was unaware that each resident had an assigned individual glucometer and was unfamiliar with the manufacturer's guidelines for the EPA-approved disinfectant wipe's contact time. This lapse in protocol was identified during the nurse's first shift at the facility, and it was confirmed that she had not received any training or education on the procedure from the facility prior to her shift. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed and revealed gaps in the orientation process for new and agency staff. The DON was not sure what the orientation entailed as it was handled by the ADON, who confirmed that the facility had recently changed the orientation process. However, the ADON was unable to specify who was responsible for completing the education on glucometer use and disinfection. Additionally, the ADON was not able to locate the communication book that should have contained the relevant guidelines and procedures. Further interviews with the Business Office Manager and the Scheduler revealed that neither were involved in the orientation process for agency staff. The Scheduler confirmed that she only obtained licensing information and did not provide any orientation training. This lack of a structured and comprehensive orientation process for agency staff led to the failure in ensuring that the agency nurse was competent in the necessary infection control procedures, resulting in the observed deficiency.
Failure to Properly Disinfect Shared Glucometer
Penalty
Summary
The facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the manufacturer's recommended contact time. This deficiency was observed during a survey when Agency Nurse #1 used the glucometer on two residents without following proper disinfection procedures. Specifically, the nurse did not maintain the required contact time of two minutes with the EPA-approved disinfectant wipe, as specified by the manufacturer's guidelines. This lapse occurred despite the facility's policy that mandates disinfection of glucometers between each use to prevent the transmission of bloodborne pathogens. During the observation, Agency Nurse #1 checked the blood glucose level of one resident and placed the glucometer back in the medication cart without disinfecting it. Later, the same glucometer was briefly wiped with a disinfectant wipe and used on another resident without adhering to the required contact time. The nurse was unaware of the specific disinfection requirements and had not received training on the proper cleaning procedures for the glucometer. This incident highlighted a significant gap in the facility's infection control practices, particularly in educating and training agency staff on the proper use and disinfection of shared medical equipment. Interviews with the Unit Manager and the Director of Nursing (DON) revealed that each resident was supposed to have their own glucometer, but this information was not communicated to the agency nurse. The DON confirmed that the glucometer should be cleaned with the disinfectant wipe for the recommended contact time of two minutes and then allowed to air dry. The failure to follow these procedures was identified as an Immediate Jeopardy situation, indicating a high likelihood of exposing residents to the spread of bloodborne pathogens due to improper disinfection practices.
Repeated Deficiencies in Infection Control, Accident Prevention, and Food Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain and monitor previously implemented procedures and interventions in the areas of Infection Prevention and Control, Food Procurement, and Accident Hazards. This failure was observed during multiple surveys, indicating a pattern of the facility's inability to sustain an effective QAA program. Specific deficiencies included improper disinfection of a shared blood glucose meter, failure to implement policies for assessing and preventing Legionella, and inadequate use of Personal Protective Equipment by visitors and dietary staff. The facility also failed to prevent two residents with impaired cognition and a history of exit-seeking behavior from exiting the facility unsupervised. One resident was found off facility property by law enforcement, and another was found in the facility parking lot. Additionally, the facility did not safeguard a cognitively impaired resident from an avoidable hazard involving bed rails and an alternating air mattress, resulting in the resident being found with no signs of life after a fall. Further deficiencies were noted in the area of food safety, where expired food was found in a walk-in cooler, and a vent cover for an ice machine was not maintained in a clean condition. These practices had the potential to affect the quality of food served to residents. Despite the QAA committee meeting monthly to review concerns and develop plans of action, the facility continued to exhibit deficiencies in the same areas over multiple surveys.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from two of four locked medication carts. During an observation of the B hall medication cart, an opened bottle containing 27 white calcium carbide tablets with an expiration date of 2/28/2024 was found. The Director of Nursing (DON) acknowledged that the expired medication should have been removed and attributed the oversight to the medication being a home medication. The medication aide confirmed that the medication belonged to a resident who no longer took it, and the physician's orders indicated it was prescribed for indigestion and heartburn as needed. Similarly, an observation of the C hall medication cart revealed a medication card with 18 Omeprazole 20 MG capsules that had expired on 2/29/2024. The Unit Manager admitted that the expired medication was overlooked during her daily cart check and that the medication was discontinued on 10/31/2023. The DON confirmed that the expired medication should have been removed and that the oversight occurred during the previous cart check. The Administrator also stated that the expectation was for all expired medications to be removed from the medication carts.
Failure to Discard Expired Food in Walk-In Cooler
Penalty
Summary
The facility failed to discard expired food in the walk-in cooler, as observed during a survey. Specifically, a container of shredded cheese, a container of chili, and a container of pureed fruit were found with preparation and use-by dates indicating they were expired. The Cook/Assistant stated that the process was to check the walk-in cooler daily for expired food, and the Dietary Manager confirmed that both she and the Cook/Assistant check the fridge every morning after breakfast. Despite these procedures, the expired items were overlooked. The Administrator also confirmed that the expectation was for all expired food to be removed from the walk-in cooler.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, as evidenced by the case of Resident #127. Resident #127, who was admitted with diagnoses including heart failure, diabetes, and chronic pain, had a physician's order for antacid tablets to be taken at bedtime. Despite having intact cognition as per the admission Minimum Data Set, there was no documentation in the medical record indicating that Resident #127 had been assessed for self-administration of medications. Observations revealed that medication was left unattended on the resident's overbed table, and the resident was unaware of its presence. Med Aide #1 confirmed that the resident had not been assessed for self-administration and that the medication should not have been left unattended. Further interviews with the Unit Manager and the Director of Nursing (DON) corroborated that Resident #127 had not been assessed for self-administration of medications and that the medication should not have been left at the bedside. The DON explained that self-administration assessments were only conducted upon the resident's request and could be completed by any nurse. The DON confirmed that the medication should have been administered directly to the resident, with the nurse waiting at the bedside to ensure it was taken. This lapse in protocol led to the deficiency noted in the report.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that code status information was accurate throughout both the paper and electronic medical records for a resident. Resident #18, who was admitted to the facility on 01/03/24, had conflicting documentation regarding her advance directive. The care plan indicated a Do Not Resuscitate (DNR) status, while the Code Book at the nurse's station contained both a DNR form and a Medical Order for Scope of Treatment (MOST) form indicating Full Code. This discrepancy was discovered during a review of the resident's electronic medical record and the Code Book on 04/04/24. Interviews with the Unit Manager, Director of Nursing (DON), and Social Worker revealed a lack of a specific process to ensure that the paper advance directives matched the electronic medical records. The Unit Manager acknowledged the need to clarify the code status with the resident's family and physician. The DON stated that the old advance directive form should be removed and replaced with the correct one, and the electronic medical record should be updated accordingly. The Social Worker mentioned that she tried to check the Code Book monthly for accuracy but confirmed that the documentation should match in both the electronic medical record and the Code Book.
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What surveyors actually found near you
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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 Hendersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Greens At Hendersonville | 1.5 mi | ★★★★★ | 2 | 0 |
| Carolina Village Inc | 2.6 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Hendersonville | 2.7 mi | ★★★★★ | 4 | 0 |
| Life Care Center Of Hendersonville | 2.9 mi | ★★★★★ | 5 | 0 |
| Hendersonville Health And Rehabilitation | 3.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.