Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Cortlandt Healthcare during CMS and state inspections, most recent first.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall, but the care plan was not updated to include a new intervention—keeping the bed in the lowest position—until several days later, despite facility policy requiring timely review and revision. Staff and physician interviews confirmed the delay in care plan documentation and implementation.
A housekeeper entered a room with both Enhanced Barrier and Contact/Droplet Precaution signage, wearing only an N95 mask and failing to use a gown, gloves, or protective eyewear as required. The housekeeper reported confusion about the required PPE due to multiple precaution signs, and the Infection Preventionist confirmed the misunderstanding. Two residents in the room were on contact/droplet precautions due to COVID-19 exposure.
A resident's discontinued Oxycodone-Acetaminophen prescription remained in the narcotic cabinet for over a month, leading to its unauthorized administration by an LPN. Despite the facility's policy for timely removal, the medication was not removed, and the Director of Nursing could not explain the oversight. The resident had diagnoses including colon cancer and emphysema, and no pain indicators were noted prior to the incident.
A medication error occurred when an LPN administered Oxycodone-Acetaminophen to a resident without a valid order, failing to follow the facility's protocol of verifying medication orders. The resident, with conditions including colon cancer and emphysema, was given the medication after a CNA reported pain, despite no recent pain indicators. The medication order had expired, and the medication was improperly kept in the medication room.
A resident with diabetes, muscle weakness, and neck pain was not provided with their preferred choice of showers over bed baths and was not facilitated to participate in favorite activities like library visits. Despite being cognitively intact and expressing these preferences, the facility failed to document or offer showers and did not arrange for the resident's desired activities.
The facility failed to provide a resident or their representative with written notification of a transfer/discharge to the hospital. Although the resident's health care proxy was informed via phone, there was no documented evidence of a written notice being provided.
The facility failed to ensure that residents were invited to participate in their care planning meetings or document reasons for non-participation. Two residents expressed interest in attending but were not invited, and there was no documentation explaining their non-participation.
The facility failed to ensure that a resident with aphasia was provided with necessary communication tools and services. Despite having a care plan that included interventions for improving communication, the resident was not effectively assessed or provided with functional communication systems. Staff were unaware of the specific communication tools to be used, leading to a deficiency in care.
A resident, assessed as needing bed rails for independence, fell and sustained injuries after the facility removed the rails without proper assessment or notification. Staff were unaware of the specific needs and orders for the resident's side rails, leading to the incident.
The facility failed to ensure that emergency equipment was readily available for a resident with a tracheostomy. Despite the care plan and policy requiring an Ambu bag at the bedside, multiple observations revealed its absence. Staff interviews confirmed the necessity of the Ambu bag, indicating a failure to comply with care requirements.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was reviewed and revised in a timely manner following a fall. The resident, who had a history of falls, a left hip fracture, and Alzheimer's disease, was admitted with a moderate risk for falls and required partial to moderate assistance with mobility and transfers. After an unwitnessed fall in the resident's room, there was no documented evidence that a new intervention—keeping the bed in the lowest position—was added to the care plan until three days later. The facility's policy required staff and practitioners to begin identifying possible causes and interventions within 24 hours of a fall, but this was not followed in this instance. Interviews with facility staff, including the DON and the primary physician, confirmed that the care plan intervention was not documented or implemented in a timely manner after the fall. The resident experienced another unwitnessed fall before the intervention was added to the care plan. Although staff reported performing routine hourly rounding, this was not documented in the care plan or care guides. The deficiency was cited under 10 NYCRR 415.11 (c)(2)(i-iii) for failure to update the care plan promptly to reflect new interventions after a fall.
Failure to Ensure Proper PPE Use for Contact/Droplet Precautions
Penalty
Summary
During a recertification survey, it was observed that a housekeeper entered a resident room on the 1st Floor that was under both Enhanced Barrier Precautions and Contact/Droplet Precautions, as indicated by signage outside the room. The housekeeper was only wearing an N95 mask while mopping the floor and did not don a gown, gloves, or protective eyewear as required for contact/droplet precautions. The housekeeper stated they had received inservice training from the Infection Preventionist the previous day but were confused by the presence of two different precaution signs and were unsure which personal protective equipment (PPE) was necessary. The Infection Preventionist confirmed the confusion and acknowledged that the housekeeper made a mistake by not wearing the appropriate PPE. The residents in the room were out of bed at the time and were on contact/droplet precautions due to exposure to other residents who had tested positive for COVID-19, although they themselves had tested negative.
Failure to Remove Discontinued Narcotic Medication
Penalty
Summary
The facility failed to ensure the timely removal of discontinued medications from the narcotic cabinet, as evidenced by the case of a resident whose Oxycodone-Acetaminophen (Percocet) prescription was discontinued but remained in the medication cabinet for over a month. The medication was discontinued on 07/11/2024, yet it was still accessible and ultimately administered without a prescriber's order on 08/18/2024 by an LPN. This incident occurred despite the facility's policy requiring that discontinued controlled substances be securely locked and removed from the unit within 24 hours of discontinuation. The resident involved had diagnoses including Malignant Neoplasm of the Colon, Emphysema, and Cardiomegaly, and was assessed to have intact cognition with no indicators of pain in the days leading up to the incident. The facility's Director of Nursing acknowledged that the medication should not have been in the medication room after discontinuation and was unable to explain why the established procedure was not followed. The LPN involved was suspended pending investigation, and a drug diversion investigation was conducted but found unsubstantiated.
Medication Error Due to Non-Compliance with Protocol
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who administered a narcotic drug, Oxycodone-Acetaminophen (Percocet), to a resident without a valid physician's order. The resident, who had diagnoses including malignant neoplasm of the colon, emphysema, and cardiomegaly, was given the medication despite having no documented indicators of pain in the previous five days. The physician's order for the medication had expired, and there was no evidence of renewal. The LPN administered the medication after being informed by a Certified Nurse Aide that the resident was in pain, without verifying the current medication order. The facility's policy required checking the physician's order three times before administering medication, which was not followed in this case. The Director of Nursing acknowledged that the medication should not have been available in the medication room after being discontinued and that the procedure for removing discontinued medications was not followed. The medication remained on the unit for seven days, contrary to the facility's protocol. The incident was reported immediately by the LPN upon realizing the error, and a drug diversion investigation was conducted, which was unsubstantiated. The resident was assessed and found to have suffered no harm from the error.
Failure to Honor Resident's Preferences for Bathing and Activities
Penalty
Summary
The facility did not ensure that Resident #21 had the right to make choices about significant aspects of their life, specifically regarding bathing preferences and participation in favorite activities. Resident #21, who had diagnoses including diabetes, generalized muscle weakness, and cervicalgia, was cognitively intact and required extensive assistance for personal hygiene and bathing. Despite the resident's documented preference for showers over bed baths, the facility's records from 9/1/23 to 10/12/23 showed that the resident was not offered or did not receive a shower on their assigned days. The resident expressed dissatisfaction with not receiving showers and felt they were declining due to the lack of physical activities, including visits to the public library, which they enjoyed and had been doing for many years. The facility's failure to honor Resident #21's preferences was further highlighted during interviews and observations. The resident stated their preference for showers and their desire to participate in activities like library visits, which had not been facilitated by the facility. The Activities Director acknowledged the lack of outside trips since COVID and mentioned an unfulfilled plan to provide the resident with an iPad. The CNA and Nurse Manager confirmed the lack of documentation and communication regarding the resident's bathing preferences and the failure to offer showers. This deficiency indicates a significant lapse in promoting and facilitating resident self-determination and choice, as required by regulations.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
The facility did not ensure that a resident or the resident's representative was notified in writing of a transfer/discharge to the hospital. This deficiency was identified for a resident with diagnoses including anemia, hypertension, and schizophrenia, whose cognition was moderately impaired. The resident was transferred to the hospital for a blood transfusion due to a very abnormal hemoglobin level. Although the resident's health care proxy was informed via phone, there was no documented evidence that a written notice of the transfer/discharge was provided to the resident or their representative. Interviews with the resident and the Social Work Director (SWD) revealed that the correct process for notification was not followed. The SWD confirmed that a letter should have been sent to the resident or responsible party immediately after the phone notification, but this was not done. The Administrator was aware that the social worker was reaching out to families regarding discharge and transfer but was not aware that written notifications were not being provided or sent.
Failure to Invite Residents to Care Planning Meetings
Penalty
Summary
The facility did not ensure that residents were offered the opportunity to participate in their care planning meetings, nor did they document an explanation in the medical records if participation was deemed impracticable. Specifically, two residents expressed interest in attending care planning meetings but reported they had not been invited. Resident #46, who has moderate cognitive impairment, hemiplegia, hemiparesis, psychosis, and Diabetes Mellitus, stated they did not recall being invited to care planning meetings. The Social Work progress note indicated that the resident's daughter attended the meeting via phone, but there was no documentation that the resident was invited or that their participation was deemed impracticable. The Social Work Director confirmed the lack of documentation and could not explain why the resident was not invited. Similarly, Resident #39, who has severe cognitive impairment, aphasia, and hemiplegia, indicated through non-verbal communication that they had not been invited to care planning meetings but would like to attend. The social work progress note documented that the resident's fiance attended the meeting via phone, but again, there was no documentation that the resident was invited or that their participation was deemed impracticable. The Social Work Director confirmed the absence of such documentation and could not provide an explanation for the oversight.
Failure to Provide Necessary Communication Tools for Resident with Aphasia
Penalty
Summary
The facility did not ensure that Resident #39, who had a diagnosis of aphasia, was provided with the necessary care and services to enable effective communication. Resident #39 was admitted with multiple diagnoses including traumatic subdural hemorrhage, aphasia following cerebrovascular disease, and hemiplegia. The resident's care plan included interventions for improving communication, such as the use of a communication board, writing, and sign language, and a referral to speech therapy for evaluation and treatment. However, the resident was last provided speech therapy in April 2023, and no further evaluations or treatments for communication were documented since then. During observations, it was noted that Resident #39 had two small dry erase boards without markers or erasers, and a small picture board, none of which were effectively used for communication. Interviews with staff revealed that they were unaware of the specific communication tools and techniques that should be used with Resident #39. The Speech Language Pathologist (SLP) admitted that they had not specifically evaluated the resident for communication needs and acknowledged that a more thorough evaluation could have been conducted. Certified Nurse Aides (CNAs) interviewed stated that they communicated with Resident #39 through head nods and eye movements, and were not informed about the use of communication boards or other tools. This lack of proper assessment and provision of functional communication systems led to the deficiency in ensuring that Resident #39 did not lose the ability to perform activities of daily living, specifically communication, without a medical reason.
Failure to Ensure Resident Safety by Removing Necessary Bed Rails
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards to prevent accidents for one resident who was assessed as needing a bed rail to promote independence. The resident, who had diagnoses including atrial fibrillation, spinal stenosis, and hypertension, was cognitively intact and required extensive assistance for bed mobility and transfers. Despite a physician's order and a care plan indicating the need for bilateral half side rails, the rails were removed without an assessment or notification to the resident or their family. This led to the resident falling out of bed, resulting in a fractured shoulder and blunt head trauma. Interviews with staff revealed that the facility received a letter from the State regarding side rail usage and decided to remove the rails without conducting assessments or providing education to staff, residents, or their families. The Registered Nurse Unit Manager, Director of Nursing, and Administrator were all unaware of the specific needs and orders for the resident's side rails. The lack of communication and proper assessment before the removal of the side rails directly contributed to the resident's fall and subsequent injuries.
Failure to Provide Emergency Respiratory Equipment
Penalty
Summary
The facility did not ensure that emergency equipment was readily available for a resident with a tracheostomy. Specifically, Resident #35, who had a diagnosis of traumatic brain injury and tracheostomy status, did not have an Ambu bag at the bedside. The resident's care plan and facility policy required an Ambu bag to be available for respiratory emergencies, but during multiple observations, no Ambu bag was found in the resident's room. Licensed Practical Nurses (LPNs) and the Respiratory Therapist confirmed that an Ambu bag should be present but was not, indicating a failure to comply with the care plan and policy requirements. Resident #35 was documented as comatose with diagnoses including respiratory failure and a tracheostomy, requiring continuous oxygen and tracheostomy care. Despite these needs, the facility failed to provide the necessary emergency equipment, as evidenced by the absence of an Ambu bag during observations on different dates. Interviews with staff revealed a lack of awareness and proper procedure for ensuring the Ambu bag was accessible, further highlighting the deficiency in providing appropriate respiratory care for the resident.
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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 Cortlandt Manor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Emerald Peek Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 0 | 0 |
| North Westchester Restorative Therapy & Nrsg Crt | 2.4 mi | ★★★★★ | 1 | 0 |
| Yorktown Rehabilitation & Nursing Center | 3.5 mi | ★★★★★ | 3 | 0 |
| New York State Veterans Home At Montrose | 4.8 mi | ★★★★★ | 4 | 0 |
| Springvale Nursing & Rehabilitation Center | 5.5 mi | ★★★★★ | 29 | 0 |
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