Inspection Reports for The Grove at Valhalla Rehabilitation and Nursing Center
NY, 10595
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 6
Sep 23, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from 09/23/2025 to 09/30/2025 to assess compliance with regulatory requirements including resident rights, abuse prevention, dementia care, medication management, and reporting of incidents.
Findings
The facility was found deficient in multiple areas including failure to ensure a safe, clean, and homelike environment; inadequate prevention and investigation of resident-to-resident abuse; delayed reporting of alleged abuse incidents; insufficient dementia care and follow-up; and inappropriate use of psychotropic medications without proper indication or response to psychiatric recommendations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a safe, clean, comfortable, and homelike environment as evidenced by strong urine odor in Resident #14's room and mattress. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from abuse, including inadequate care planning and monitoring of Resident #14's wandering and resident-to-resident altercations involving Residents #8 and #118. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and submit investigation results within required timeframes for an incident involving Resident #170 and a Registered Nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct a thorough investigation of an alleged abuse incident involving Resident #170 to resolve inconsistencies and rule out abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and services to Resident #14 with dementia, including lack of person-centered interventions and failure to schedule recommended neurology follow-up after hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #14's drug regimen was free from unnecessary drugs, including administration of Haldol 2 mg without labeled indication and without following psychiatrist's recommendation to reduce dosage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 20
Residents reviewed for dementia care: 3
Falls at night: 3
Days late for 5-day report submission: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #12 | Registered Nurse | Involved in alleged abuse incident with Resident #170 during medication administration |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed and reported alleged abuse incident involving Resident #170 and Registered Nurse #12 |
| Unit Manager #13 | Nurse Manager | Responded to alleged abuse incident involving Resident #170 and Registered Nurse #12 |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding abuse reporting and investigation expectations |
| Director of Nursing #2 | Director of Nursing | Completed incident report for abuse involving Resident #170 (no longer at facility) |
| Registered Nurse Supervisor #15 | Registered Nurse Supervisor | Notified of abuse incident involving Resident #170 |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Interviewed regarding Resident #14's dementia and wandering behaviors |
| Certified Nurse Aide #20 | Certified Nurse Aide | Interviewed regarding Resident #14's wandering and behaviors |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding management of Resident #14's wandering behaviors |
| Medical Director | Medical Director | Primary care physician for Resident #14, interviewed regarding neurology follow-up and psychiatric recommendations |
| Psychiatrist | Psychiatrist | Provided recommendations to reduce Resident #14's Haldol dosage |
Inspection Report
Recertification
Capacity: 160
Deficiencies: 13
Sep 23, 2025
Visit Reason
The survey was conducted as a recertification and abbreviated survey from 09/23/2025 to 09/30/2025 to assess compliance with regulatory requirements for The Grove at Valhalla Rehab and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to provide residents with notices in understandable formats, maintain a safe and clean environment, protect residents from abuse, timely report and investigate abuse allegations, provide adequate assistance with activities of daily living, maintain hearing aids, ensure sufficient nursing staff, provide appropriate dementia care, avoid unnecessary drug use, provide special eating equipment, ensure food safety, and implement infection prevention and control programs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Residents did not receive contact information for the New York State Department of Health in a format and language they could understand. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure resident's right to a safe, clean, comfortable and homelike environment; odor of urine observed in resident's room and mattress. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not protect residents from abuse; inadequate plans to prevent resident-to-resident abuse and wandering behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not timely report suspected abuse and delayed submission of investigation report to state survey agency. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not complete thorough investigation of alleged abuse to resolve inconsistencies and rule out abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Resident did not receive necessary assistance for bathing to maintain personal hygiene; inconsistent showers provided. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain accountability and safe storage of resident's hearing aids, resulting in missing hearing aids. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not provide sufficient nursing staff to meet resident needs, resulting in delays and inadequate care. | Level of Harm - Minimal harm or potential for actual harm |
| Resident diagnosed with dementia did not receive appropriate treatment and services to maintain highest practicable well-being; lack of follow-up neurology consult and inadequate person-centered interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Resident received unnecessary drugs; Haldol ordered without labeled indication and without following psychiatrist's recommendation to reduce dosage. | Level of Harm - Minimal harm or potential for actual harm |
| Resident did not receive special eating equipment as ordered; built-up utensils not provided as per physician order. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure proper food storage, preparation, distribution, and service; missing temperature logs, expired and unlabeled food items in kitchen and resident refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not establish and maintain an infection prevention and control program; staff failed to wear required personal protective equipment during resident transfer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 160
Deficiencies cited: 13
Residents with Behavioral Health Needs: 34
Residents with Dementia: 29
Residents with Depression: 34
Residents needing assistance with dressing: 114
Residents needing assistance with bathing: 126
Residents needing assistance with transferring: 115
Residents needing assistance with eating: 137
Dependent residents for dressing: 41
Dependent residents for bathing: 29
Dependent residents for transfer: 39
Dependent residents for eating: 17
Dependent residents for toileting: 38
Residents requiring mechanical lift: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Responsible for ensuring required contact information for NY State Department of Health was posted | |
| Administrator | Interviewed regarding housekeeping and awareness of urine odor in resident room | |
| Certified Nurse Aide #20 | Certified Nurse Aide | Interviewed about Resident #14 wandering behavior and interventions |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Interviewed about Resident #14 wandering behavior and staffing |
| Assistant Director of Nursing | Interviewed about management of Resident #14 wandering and abuse investigations | |
| Medical Director | Primary Care Physician | Interviewed about Resident #14 care and psychiatrist recommendations |
| Certified Nurse Aide #14 | Certified Nurse Aide | Interviewed about bathing assistance for Resident #114 |
| Licensed Practical Nurse #24 | Licensed Practical Nurse | Interviewed about missing hearing aids of Resident #8 |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Interviewed about missing hearing aids of Resident #8 |
| Director of Human Resources/Staffing Coordinator | Interviewed about staffing and scheduling | |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about staffing and shower assistance |
| Resident #170 | Alleged abuse incident involving Registered Nurse #12 | |
| Registered Nurse #12 | Registered Nurse | Involved in alleged abuse incident with Resident #170 |
| Registered Nurse Unit Manager #13 | Registered Nurse Unit Manager | Reported and investigated alleged abuse incident involving Resident #170 |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed alleged abuse incident involving Resident #170 |
| Director of Nursing #1 | Director of Nursing | Interviewed about abuse reporting and investigation procedures |
| Director of Nursing #2 | Director of Nursing | Completed incident report for alleged abuse involving Resident #170 |
| Registered Nurse Supervisor #16 | Registered Nurse Supervisor | Notified of alleged abuse incident involving Resident #170 |
| Nurse Practitioner | Nurse Practitioner | Provided medical evaluation following alleged abuse incident involving Resident #170 |
| Dietician #1 | Dietician | Interviewed about special eating equipment for Resident #3 |
| Director of Rehabilitation | Interviewed about evaluation and ordering of special eating equipment for Resident #3 | |
| Home Health Aide #18 | Home Health Aide | Observed transferring Resident #12 without required PPE |
| Home Health Aide #19 | Home Health Aide | Observed transferring Resident #12 without required PPE |
| Certified Nurse Aide #17 | Certified Nurse Aide | Observed transferring Resident #12 without required PPE |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control program and staff training |
| Psychiatrist | Psychiatrist | Recommended reduction of Haldol dosage for Resident #14 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
May 9, 2024
Visit Reason
Life Safety Code citation for sprinkler system maintenance and testing, corrected as of May 22, 2024.
Findings
Life Safety Code citation for sprinkler system maintenance and testing, corrected as of May 22, 2024.
Deficiencies (1)
| Description | Severity |
|---|---|
| Sprinkler system - maintenance and testing | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Feb 14, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with care plan updates and resident safety, including investigation of skin impairments and accident hazards.
Findings
The facility failed to timely update care plans to reflect residents' changing needs, specifically for a resident with multiple wounds. Additionally, inadequate supervision led to a resident suffering a burn injury from spilled hot coffee. The facility has since implemented new care plan update procedures and staff training on food safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident's Care Plan was reviewed and revised to reflect changing needs, specifically for skin impairments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and maintain a safe environment, resulting in a resident sustaining a 3x3 inch blistering burn from spilled hot coffee. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Wound size: 5
Wound size: 25
Wound size: 15
Burn size: 3
BIMS score: 12
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Reported audit findings and new care plan update procedures; provided staff training on food safety after burn incident |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding care plan responsibilities and coffee reheating incident |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding care plan update responsibilities |
| Staff #1 | Certified Nursing Assistant involved in coffee reheating and spill incident causing resident burn |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Feb 14, 2024
Visit Reason
Standard Health citations for care plan timing and revision and free of accident hazards/supervision/devices, both corrected as of April 23, 2024.
Findings
Standard Health citations for care plan timing and revision and free of accident hazards/supervision/devices, both corrected as of April 23, 2024.
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plan timing and revision | Level 2 |
| Free of accident hazards/supervision/devices | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 30, 2023
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from 3/22/2023 through 3/30/2023 to assess compliance with regulatory requirements for The Grove at Valhalla Rehab and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to notify residents or their representatives in writing about the bed hold policy during hospital transfers, failure to develop and implement comprehensive person-centered care plans for several residents, and inadequate pressure ulcer care resulting in actual harm to a resident due to delayed wound consultation and treatment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify residents or their representatives in writing of the facility's Bed Hold Policy during hospital transfers for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans for 5 of 7 residents reviewed, including lack of care plans for weekly weights, thyroid disorder, assistance with eating, and pressure ulcer risk or presence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm for one resident due to delayed wound consult and treatment. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for Care Plans: 7
Residents affected by bed hold notification deficiency: 2
Residents affected by care plan deficiency: 5
Residents affected by pressure ulcer care deficiency: 1
Pressure ulcer wound size: 12
Pressure ulcer wound size: 17
Pressure ulcer wound size: 0.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated bed hold notifications are the responsibility of staff sending residents out; acknowledged failure to notify residents about bed hold policy; involved in care plan review and wound care findings |
| Administrator | Facility Administrator | Confirmed failure to notify residents about bed hold policy |
| RN #2 | Wound Nurse | Provided statements about wound care responsibilities and resident wound status |
| RN #3 | Registered Nurse | Responsible for initiating and updating care plans; aware of wound consult delay |
| RN #6 | Registered Nurse | Discussed care plan responsibilities and deficiencies |
| NP #1 | Nurse Practitioner | Provided wound care and progress notes; acknowledged use of template notes and lack of direct skin assessment |
| Wound care physician #1 | Wound Care Physician | Assessed and treated unstageable sacral wound; noted wound did not occur overnight |
| Medical Director | Medical Director | Discussed wound assessment and lack of documentation; recommended hospital transfer for wound management |
| LPN #1 | Licensed Practical Nurse | Administered wound treatments; did not report worsening wound |
| CNA #1 | Certified Nursing Assistant | Reported noticing scratches on resident's coccyx and reporting to nurse |
| CNA #9 | Certified Nursing Assistant | Provided care in September 2022; observed redness and rash on sacrum; reported nurse applied treatment |
| CNA #10 | Certified Nursing Assistant | Provided care during September-October 2022; observed open bed sore on sacrum; called nurse to apply treatment |
Inspection Report
Annual Inspection
Deficiencies: 11
Mar 30, 2023
Visit Reason
The inspection was a recertification survey conducted from 3/22/2023 to 3/30/2023 to assess compliance with regulatory requirements for The Grove at Valhalla Rehab and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident dignity, environment safety, notification of transfers and bed hold policies, timely resident assessments, care plan development and implementation, assistance with activities of daily living, medication administration, nutrition and hydration, accident hazard prevention, and infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Resident dignity was compromised when a Foley catheter bag was left uncovered with urine visible to staff, residents, and visitors. | Level of Harm - Minimal harm or potential for actual harm |
| A window unit air conditioner in a resident's room was in disrepair with visible gaps to the outdoors, posing safety and comfort issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely written notification to resident and representatives regarding hospital transfer and discharge, including ombudsman notification. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify residents or representatives in writing of the facility's bed hold policy during hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Quarterly Minimum Data Set (MDS) assessments were not completed within required time frames. | Level of Harm - Minimal harm or potential for actual harm |
| Incomplete or missing comprehensive care plans for multiple residents, including lack of plans for pressure ulcers, thyroid disorder, and assistance with eating. | Level of Harm - Minimal harm or potential for actual harm |
| Resident not provided necessary assistance with meals as planned, resulting in inadequate nutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration omissions for Resident #23, with 13 missed doses documented within 14 days. | Level of Harm - Minimal harm or potential for actual harm |
| Portable electric space heaters were observed in resident rooms without proper maintenance inspection or approval, posing accident hazards. | Level of Harm - Minimal harm or potential for actual harm |
| Housekeeper observed distributing linens from an uncovered linen cart and handling linens in an unclean manner, risking infection spread. | Level of Harm - Minimal harm or potential for actual harm |
| Weekly weight monitoring for Resident #38 was not implemented as ordered, affecting nutrition assessment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration omissions: 13
Pressure injury size: 12
Pressure injury size: 17
Pressure injury size: 0.2
Resident weight: 164.2
Resident weight: 145.8
Resident weight: 134.8
Resident weight: 132
Resident weight: 134.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding uncovered Foley catheter dignity bag. |
| RN #5 | Registered Nurse | Interviewed regarding Foley catheter dignity bag and weight monitoring. |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding window unit AC gaps and cold room. |
| Director of Building Services | Director of Building Services | Interviewed regarding window unit AC and linen handling. |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer notifications, bed hold policy, care plans, and medication administration. |
| RN #1 | Registered Nurse MDS Coordinator | Interviewed regarding delayed quarterly MDS submission. |
| RN #2 | Registered Nurse | Interviewed regarding wound care and medication administration omissions. |
| RN #3 | Registered Nurse | Interviewed regarding care plan responsibilities and weight monitoring. |
| RN #6 | Registered Nurse | Interviewed regarding care plans for pressure ulcer prevention. |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #114. |
| CNA #7 | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #114. |
| Dietitian #2 | Dietitian | Interviewed regarding feeding assistance for Resident #114. |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding linen handling. |
| Registered Nurse Supervisor (RN #7) | Registered Nurse Supervisor | Interviewed regarding medication administration omissions. |
| Registered Nurse (RN #8) | Registered Nurse Supervisor | Interviewed regarding medication administration omissions. |
| Registered Dietitian (RD#1) | Registered Dietitian | Interviewed regarding weight monitoring. |
| Administrator | Administrator | Interviewed regarding transfer notifications, bed hold policy, and space heaters. |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 3, 2022
Visit Reason
Standard Health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
Standard Health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 6
Aug 21, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for The Grove at Valhalla Rehab and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to implement comprehensive care plans, inadequate assistance with activities of daily living, failure to provide prescribed skin treatments, improper food storage practices, inadequate infection control practices, and malfunctioning resident call systems.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to implement a comprehensive care plan for fluid restriction for Resident #47, resulting in fluid intake exceeding physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living, evidenced by Resident #48 having untrimmed nails over multiple days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide prescribed skin treatments for Resident #39, who did not receive dermatologist-ordered creams for skin conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain opened and outdated potentially hazardous foods in accordance with professional standards, including defrosted fish and ground beef stored beyond recommended timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper hand hygiene and infection control practices during wound care for Resident #99, including use of soiled gloves and contamination of supplies. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain working call systems in resident bathrooms, with emergency call bells in three bathrooms found nonfunctional and unreported. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Average daily fluid intake with meals: 1110
Average daily fluid intake with medication pass: 440
Total average daily fluid intake: 1550
Average daily fluid intake with meals: 670
Average daily fluid intake with medication pass: 342
Total average daily fluid intake: 1012
Dates since opened: 4
Dates since opened: 3
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 1
Number of bathrooms affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RD #1 | Registered Dietitian | Interviewed regarding fluid restriction compliance for Resident #47 |
| CNA #1 | Certified Nurses Aide | Interviewed regarding Resident #47's eating and fluid intake |
| Registered Nurse Manager | Unit 1 North RNM | Interviewed regarding monitoring of CNA fluid documentation |
| RN #1 | Registered Nurse Unit Manager | Interviewed regarding personal care and nail trimming for Resident #48 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding personal care and nail trimming for Resident #48 |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding lack of prescribed skin treatments for Resident #39 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding lack of prescribed skin treatments for Resident #39 |
| RN #3 | Registered Nurse Manager | Interviewed regarding lack of prescribed skin treatments and receipt of creams for Resident #39 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding receipt and application of prescribed creams for Resident #39 |
| Food Service Director | Food Service Director | Interviewed regarding food storage and safety practices |
| LPN #4 | Licensed Practical Nurse | Observed and interviewed regarding improper hand hygiene during wound care for Resident #99 |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding malfunctioning call bells in resident bathrooms |
| Corporate Maintenance Worker | Maintenance Worker | Interviewed regarding call bell maintenance and repair |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Interviewed regarding awareness of call bell malfunctions |
Loading inspection reports...
