Inspection Reports for
Cortlandt Healthcare
110 Oregon Road, Cortlandt Manor, NY, 10567
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
161% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 15, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with care plan review and revision requirements following a resident fall.
Findings
The facility failed to timely update the care plan for one resident after a fall, delaying implementation of a bed-in-low-position intervention by three days. Interviews confirmed the care plan intervention was not documented in a timely manner as required by facility policy.
Deficiencies (1)
F 0657: The facility did not ensure the resident's care plan was reviewed and revised timely after a fall on 07/18/2025, with the bed-in-low-position intervention added only on 07/21/2025. The delay violated the facility's Falls-Clinical Protocol requiring intervention identification within 24 hours.
Report Facts
Fall Risk Score: 69
Fall Risk Score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #9 | Registered Nurse | Documented admission evaluation and baseline care plan for Resident #1 |
| Certified Nurse Aide #2 | Certified Nurse Aide | Observed Resident #1 on the floor after fall on 07/18/2025 |
| Director of Nursing | Interviewed regarding delay in care plan intervention implementation | |
| Primary Physician | Interviewed regarding untimely documentation of care plan intervention | |
| Facility Administrator | Interviewed regarding expectations for timely care plan updates |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Mar 3, 2025
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies including infection control, immunizations, drug labeling, cooking facilities, electrical systems, fire alarm system, HVAC, sprinkler system, and building space subdivisions. Most deficiencies were Level 2 severity and many were corrected by April 2025.
Findings
Inspection identified multiple standard health and life safety code deficiencies including infection control, immunizations, drug labeling, cooking facilities, electrical systems, fire alarm system, HVAC, sprinkler system, and building space subdivisions. Most deficiencies were Level 2 severity and many were corrected by April 2025.
Deficiencies (13)
Infection control
Infection prevention & control
Influenza and pneumococcal immunizations
Label/store drugs and biologicals
Cooking facilities
Electrical systems - essential electric system
Fire alarm system - testing and maintenance
Hvac
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrier
Physical environment
Standards of construction for new existing nursing home
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 3, 2025
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with infection prevention and control requirements.
Findings
The facility failed to maintain proper infection prevention practices in one of three resident units. A housekeeper was observed not wearing the required personal protective equipment in a contact/droplet precaution room due to confusion caused by conflicting signage.
Deficiencies (1)
F 0880: The facility did not ensure infection prevention was maintained. Housekeeper #3 entered a contact/droplet precaution room without wearing gown, gloves, or protective eyewear, despite being on precautions due to COVID-19 exposure.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #3 | Observed not wearing required PPE in contact/droplet precaution room. | |
| Infection Preventionist | Interviewed regarding PPE confusion and infection control practices. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
Inspection found isolated Level 2 deficiencies related to pharmacy services, procedures, pharmacist records, and medication error prevention. All deficiencies were corrected by December 2024.
Findings
Inspection found isolated Level 2 deficiencies related to pharmacy services, procedures, pharmacist records, and medication error prevention. All deficiencies were corrected by December 2024.
Deficiencies (2)
Pharmacy services/procedures/pharmacist/records
Residents are free of significant med errors
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with pharmaceutical services and medication administration policies.
Findings
The facility failed to ensure timely removal of discontinued controlled medications from the narcotic cabinet and allowed administration of a discontinued medication without a prescriber's order. Licensed Practical Nurse #10 administered Oxycodone-Acetaminophen to a resident without an active order, violating facility policy.
Deficiencies (2)
F 0755: The facility did not ensure timely removal of discontinued controlled medications from the narcotic cabinet. A discontinued Oxycodone-Acetaminophen tablet remained accessible and was administered without a prescriber's order.
F 0760: The facility did not ensure residents were free from medication errors. Licensed Practical Nurse #10 administered a discontinued narcotic medication to a resident without an order.
Report Facts
Residents reviewed for medications: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #10 | Named in medication error finding for administering discontinued medication without order | |
| Licensed Practical Nurse #11 | Interviewed regarding narcotic removal procedures | |
| Director of Nursing | Director of Nursing | Provided statements on medication removal procedures and follow-up interviews |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Date: Oct 18, 2023
Visit Reason
Inspection identified multiple isolated Level 2 standard health deficiencies related to activities of daily living, care plan revisions, accident hazards, investigation of alleged violations, transfer/discharge notices, respiratory care, and self-determination. Life safety code deficiencies included cooking facilities, egress doors, electrical equipment, fire alarm system, gas equipment, door maintenance, sprinkler system, and building space subdivisions. Most deficiencies were corrected by December 2023.
Findings
Inspection identified multiple isolated Level 2 standard health deficiencies related to activities of daily living, care plan revisions, accident hazards, investigation of alleged violations, transfer/discharge notices, respiratory care, and self-determination. Life safety code deficiencies included cooking facilities, egress doors, electrical equipment, fire alarm system, gas equipment, door maintenance, sprinkler system, and building space subdivisions. Most deficiencies were corrected by December 2023.
Deficiencies (18)
Activities daily living (ADLs)/maintain abilities
Care plan timing and revision
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Notice requirements before transfer/discharge
Respiratory/tracheostomy care and suctioning
Self-determination
Cooking facilities
Egress doors
Electrical equipment - power cords and extensions
Electrical systems - essential electric system
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storage
Maintenance, inspection & testing - doors
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrier
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
The visit was conducted as a recertification abbreviated survey to assess compliance with regulations, including investigation of alleged resident neglect.
Findings
The facility failed to fully investigate an allegation of resident neglect involving Resident #372 being left in a chair for two shifts overnight. The investigation was incomplete, and the allegation was not reported to the New York State Department of Health as required.
Deficiencies (1)
F 0610: The facility did not ensure that an allegation of resident neglect was fully investigated and did not report the allegation to the New York State Department of Health. Documentation was lacking for care provided during the shifts in question, and the Director of Nursing was unaware of the allegation.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RNUM) #1 | Interviewed regarding the neglect allegation and investigation | |
| Director of Nursing (DON) | Interviewed and stated unawareness of the allegation and that it would have been investigated if known |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 18, 2023
Visit Reason
The survey was conducted as a recertification annual inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident choice and self-determination, timely notification of hospital transfers, resident participation in care planning, communication support for residents with aphasia, accident hazard prevention related to side rail removal, and availability of emergency respiratory equipment.
Deficiencies (6)
F 0561: The facility did not ensure Resident #21 was provided choice regarding bathing method or participation in preferred activities including library visits.
F 0623: The facility failed to provide written notification to Resident #61 or their representative about hospital transfer including effective date, location, and reason.
F 0657: The facility did not ensure Residents #46 and #39 were offered the opportunity to participate in their care planning meetings or documented reasons for non-participation.
F 0676: Resident #39 with aphasia was not provided adequate assessment or treatment to support communication including use of functional communication systems.
F 0689: Resident #28 fell and sustained injury after side rails were removed without assessment or education to resident or family.
F 0695: Resident #35 with tracheostomy did not have an Ambu bag readily available at bedside for respiratory emergencies.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager #2 | Nurse Manager | Reviewed bathing/shower documentation for Resident #21 |
| Social Work Director | Social Work Director | Reviewed care planning records and transfer notification process |
| Activities Director | Activities Director | Discussed resident activities and care plan assessments |
| CNA #1 | Certified Nurse Aide | Provided information on bathing preferences and side rail removal |
| Speech Language Pathologist | Speech Language Pathologist | Evaluated Resident #39's speech and communication needs |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Discussed side rail removal and related assessments |
| Director of Nursing | Director of Nursing | Responded to fall incident involving Resident #28 |
| Administrator | Administrator | Provided information on facility policies and awareness of deficiencies |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Unable to locate Ambu bag for Resident #35 |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Discussed emergency respiratory equipment for Resident #35 |
| Respiratory Therapist #1 | Respiratory Therapist | Described required emergency equipment for Resident #35 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 25, 2023
Visit Reason
Inspection found an isolated Level 2 deficiency related to accident hazards, supervision, and devices. The deficiency was corrected by June 2023.
Findings
Inspection found an isolated Level 2 deficiency related to accident hazards, supervision, and devices. The deficiency was corrected by June 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 25, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety regulations related to accident hazards and supervision to prevent accidents.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents for one resident who fell forward out of their wheelchair during transport, resulting in a nasal bone fracture and head contusion. Video review and staff interviews confirmed the resident's feet were not positioned on the wheelchair footrest during transport.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident falling forward out of their wheelchair during transport and sustaining injuries.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in incident involving resident fall during wheelchair transport |
| CNA #2 | Certified Nurse Aide | Witnessed and reported details of resident fall during wheelchair transport |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training and incident review |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 2, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The survey identified multiple deficiencies related to care planning, respiratory care, pressure ulcer care, bladder continence management, infection control, and maintenance of the call bell system. Several residents did not have appropriate or updated care plans, and staff did not consistently follow physician orders or proper procedures.
Deficiencies (7)
F0656: The facility failed to develop and implement a complete care plan for residents #53 and #35, including range of motion and respiratory care interventions.
F0657: The facility did not review and revise comprehensive care plans with measurable objectives and appropriate interventions for resident #44 regarding urinary continence.
F0686: The facility failed to provide appropriate pressure ulcer care for resident #23, specifically not applying bilateral heel booties as ordered.
F0690: The facility did not provide necessary care to promote and maintain bladder continence for resident #44, lacking identification of incontinence type and appropriate care plans.
F0695: The facility failed to provide safe and appropriate respiratory care for resident #35 by not following physician's oxygen administration orders.
F0880: The facility did not ensure proper hand hygiene during wound care treatment for resident #23, risking infection.
F0919: The facility failed to maintain the resident call bell system in proper working order on the 1st floor, impairing resident communication.
Report Facts
Deficiencies cited: 7
Pressure ulcer measurements: 3
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in respiratory care and wound care findings for residents #35 and #23. |
| RNUM #1 | Registered Nurse Unit Manager | Named in respiratory care and bladder continence care plan findings. |
| RNUM #2 | Registered Nurse Unit Manager | Named in care plan development finding for resident #53. |
| CNA #1 | Certified Nursing Assistant | Named in pressure ulcer care findings for resident #23. |
| CNA #2 | Certified Nursing Assistant | Named in pressure ulcer care findings for resident #23. |
| CNA #3 | Certified Nursing Assistant | Named in bladder continence care findings for resident #44. |
| Director of Maintenance | Named in call bell system maintenance findings. |
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