The Grove At Valhalla Rehab And Nursing Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record review conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for one (Resident #14) of three residents reviewed for dementia care. Specifically, an odor of urine was observed in Resident #14's room and coming from their mattress.

The findings are: The facility policy titled Cleaning and Disinfection of Environmental Surfaces dated 06/02/2025 documented non-critical environmental surfaces can be decontaminated where they are used.

On 09/25/2025 at 11:25 AM, Resident #14's room was observed with a strong odor of stale urine and body odor. The odor appeared strongest near the resident's bare mattress. On 09/26/2025 at 5:20 PM, Resident #14's room was observed with a strong odor of urine without Resident #14 present in the room. On 09/30/2025 at 2:17 PM, the Administrator was interviewed and stated the former Housekeeping Director left

a few weeks ago and the Administrator was currently covering. Environmental rounds for cleanliness were performed at least daily by housekeeping staff and/or the Administrator. The Administrator stated the housekeeping staff were responsible for cleaning resident mattresses daily during standard resident room cleaning. Nursing staff were responsible for alerting housekeeping staff if a resident's mattress required cleaning outside of the normal daily room cleaning. Housekeeping replaced mattresses as needed if damaged or particularly soiled. The Administrator stated they were unaware that Resident #14's room had

a strong odor of urine. 10 NYCRR 415.5(h)(2)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Grove at Valhalla Rehab and Nursing Center

61 Grasslands Road Valhalla, NY 10595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

09/30/2025 at 2:17PM, the Administrator was interviewed and stated they were aware that Resident #14 had a behavior of wandering but was unaware that this was a problem at night or early in the morning. The Administrator stated they were responsible for reviewing the grievance and accident/incident investigations and signing off on the investigation conclusions determined by the investigating department head. The Administrator stated Resident #14 was easily redirectable and did not have bad intentions.10 NYCRR 415.4(b)(1)(i)

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Grove at Valhalla Rehab and Nursing Center

61 Grasslands Road Valhalla, NY 10595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609

incident occurred. 10NYCRR 415.4(b)(1)(ii)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Grove at Valhalla Rehab and Nursing Center

61 Grasslands Road Valhalla, NY 10595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

frustrated and refused the medications. Resident #170 stated that Registered Nurse #12 tried to force the medications into their mouth and started screaming get away from me! Unit Manager #13 documented this was confirmed by Certified Nurse Aide #2. Registered Nurse #12 stated they attempted to restrain Resident #170 arms because they were hitting them. Unit Manager #13 informed Registered Nurse #12 it was never appropriate to restrain a resident and force medications into their mouth when they refused. Unit Manager #13 notified the Director of Nursing and Registered Nurse Supervisor #15 of the incident.There was no documented evidence Registered Nurse Unit Manager #13 assessed the resident or wrote a progress note or started and accident/incident report after the incident.A Nurse Practitioner progress note dated 3/13/2024 at 4:15 PM, documented the resident was seen as requested by nursing for evaluation and had a superficial abrasion to the right wrist/hand.The facility's report submitted to the New York State Department of Health, by the Director of Nursing #2 on 3/13/2024 at 5:49 PM documented on 3/12/2024 staff reported to Registered Nurse Unit Manager #13 that there was a situation with the patient and nurse administering medication. While Registered Nurse #12 was attempting to administer medications, Resident #170 became upset, yelled at and started to hit Registered Nurse #12 who was blocking the blows. 911 was activated to diffuse the situation and no report was filed. Resident #170 alleged Registered Nurse #12 held their hands.

On 3/13/2024, a head-to-toe assessment was completed a Registered Nurse and Nurse Practitioner, and a two-to-three-centimeter scratch was discovered on Resident #170 right wrist. The report documented the nurse was removed from duty pending investigation immediately and several versions of the story were rendered. A review of the 5-day report investigative conclusion submitted to the New York State Department of Health on 04/25/2024 documented that it was undetermined to believe that abuse, neglect, or mistreatment occurred, and the findings were inconclusive.When requested on 9/29/2025, the facility was unable to provide any additional documentation including additional interviews to clear inconsistencies and determine why the investigation conclusion was inconclusive. In an interview on 9/29/2025 at 4:50 PM, Resident #170 stated they were not familiar with incident and did not remember the staff member. Resident #170 stated they have had problems with some staff members and admitted to yelling, calling names and throwing items at them. Near the end of the interview after refreshing their recollection, Resident #170 remembered the gender of the registered nurse, and stated they may have been struck by Registered Nurse #12 while Registered Nurse #12 was blocking their throws. Resident #170 stated they had no stress about the incident.In a telephone interview on 09/30/2025 at 12:02 PM, Certified Nurse Aide #2 stated they did not remember everything about the incident. They remember hearing Resident #170 screaming at Registered Nurse #12 and Registered Nurse #12 told them to get the supervisor. Certified Nurse Aide #2 did not see anything physical between the Resident #170 and Registered Nurse #12 and did not remember telling Unit Manager #13 that Registered Nurse #12 was attacking the resident. They did not remember anyone questioning them after the incident.During an interview on 9/30/2025 at 1:10 PM, Director of Nursing #1 stated their expectation was for the staff to immediately inform a supervisor and then notify the Director of Nursing or Administrator of abuse allegations. The Director of Nursing had two (2) hours to report the incident to the Department of Health. An investigation was to be completed, usually within four (4) days, and then the 5-day report investigation conclusion was sent to the Department of Health. All people who were part of incident were to be interviewed. The investigator needed to learn the facts and try to determine a conclusion to the incident. If there were inaccurate or different versions of the story, then

they must reinterview people to determine why there were different versions.10NYCRR 415.4(b)(3)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Grove at Valhalla Rehab and Nursing Center

61 Grasslands Road Valhalla, NY 10595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744

neurology consults or follow-ups since their hospitalization in 08/2025. 10 NYCRR 415.12

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Grove at Valhalla Rehab and Nursing Center

61 Grasslands Road Valhalla, NY 10595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

readmitted with an order for Haldol 2 milligrams every 6 hours as needed. The Psychiatrist stated they evaluated Resident #14 and most recently recommended lowering the resident's Haldol order from 2 milligrams to 1 milligrams every six hours. The Psychiatrist stated they received reports from nursing staff that Resident #14's wandering behavior had decreased and determined Resident #14 no longer displayed irritability or paranoid ideation. The Psychiatrist stated they verbally communicated directly with Resident #14's primary Physician, the facility's Medical Director, regarding the recommendation to decrease the resident's Haldol. On 09/29/2025 at 1:12 PM, the Medical Director, Resident #14's primary care physician, was interviewed via telephone and stated they did not question the Psychiatrist's recommendations, whether to start a new or reduce an existing one and ordered whatever the Psychiatrist documented in their consults. The Medical Director stated Resident #14 had a diagnosis of dementia, but their psychotic symptoms made psychosis their primary diagnosis. The Medical Director stated they were previously unaware of the Psychiatrist's recommendation on 09/13/2025 to reduce Resident #14's Haldol order from 2 milligrams to 1 milligrams every six hours. 10 NYCRR 415.12(l)(1)

Event ID:

Facility ID:

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