Cycle 1
Health 2025-03-03 · Fire 2025-03-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cortlandt Manor, NY
Cortlandt Healthcare
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
110 Oregon Road, Cortlandt Manor, NY
(914) 739-9150
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1977-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,174
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.74
Baseline 17.18% · Performance 17.38% · Measure score 8.74 · Achievement 8.74 · Improvement 0
Healthcare-associated infections
0
Baseline 6.35% · Performance 7.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.67
Baseline 35.51% · Performance 32.32% · Measure score 7.67 · Achievement 7.67 · Improvement 2.49
Adjusted total nurse staffing
0
Baseline 2.98 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 12% · Lower 95% interval 8.35% |
| Discharge to community | 45.79% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 248 · Observed rate 38.71% · Lower 95% interval 40.05% |
| Medicare spending per beneficiary | 1.62 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 95.92% |
95.27%
0.7 pts better
|
Numerator 188 · Denominator 196 |
| Falls with major injury | 1.53% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 196 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 78 · Denominator 138 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 92 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 4.59% |
2.29%
2.3 pts worse
|
Numerator 9 · Denominator 196 · Adjusted rate 3.47% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 167 · Observed rate 9.58% · Lower 95% interval 5.31% |
| Staff COVID-19 vaccination coverage | 0.55% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 181 |
| Staff flu vaccination coverage | 87.98% |
42%
46 pts better
|
Numerator 161 · Denominator 183 |
| Discharge function score | 63.77% |
56.45%
7.3 pts better
|
Numerator 88 · Denominator 138 |
| Transfer of health information to provider | 91.23% |
95.95%
4.7 pts worse
|
Numerator 52 · Denominator 57 |
| Transfer of health information to patient | 97.8% |
96.28%
1.5 pts better
|
Numerator 89 · Denominator 91 |
| Resident COVID-19 vaccinations up to date | 8.93% |
25.2%
16.3 pts worse
|
Numerator 10 · Denominator 112 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
91.2%
0.7 pts worse
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 89.5% · Q3 86.7% · Q4 89.0% · 4Q avg 90.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
95.3%
3.1 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 2.2% · Q4 4.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.7% |
18.5%
0.8 pts better
|
11.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 19.5% · Q3 14.3% · Q4 16.7% · 4Q avg 17.7% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
6.1%
1.6 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.4% · Q3 11.6% · Q4 5.1% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.8% |
13.5%
4.3 pts worse
|
19.6%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 18.6% · Q3 15.6% · Q4 19.5% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
14.8%
7.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.5% · Q3 7.9% · Q4 5.3% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.4% |
15.1%
12.3 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 25.9% · Q3 19.9% · Q4 27.5% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
15.5%
2.7 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 17.3% · Q3 16.4% · Q4 21.1% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.4%
0.8 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
20.8%
8.7 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 31.9% · Q3 30.0% · Q4 34.5% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.9%
2.9 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 1.1% · Q3 6.8% · Q4 2.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
76.7%
13.3 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 92.4% · Q3 93.2% · Q4 83.3% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
9.7%
3 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
78.8%
14.5 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
20.6%
4.1 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2020-10-02 · Fire 2020-10-02
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-24
E · Potential for more than minimal harm
2023-10-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-01
E · Potential for more than minimal harm
2020-10-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-11-27
E · Potential for more than minimal harm
2020-10-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-11-27
D · Potential for more than minimal harm
2020-10-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-11-27
D · Potential for more than minimal harm
2020-10-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-11-27
D · Potential for more than minimal harm
2020-10-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-11-27
C · Minimal harm
2020-10-02
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2020-11-27
C · Minimal harm
2020-10-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-11-27
C · Minimal harm
2020-10-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-11-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-21
D · Potential for more than minimal harm
2025-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
D · Potential for more than minimal harm
2024-10-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-10-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-09
D · Potential for more than minimal harm
2023-10-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-05-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-23
E · Potential for more than minimal harm
2020-10-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-12-01
E · Potential for more than minimal harm
2020-10-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2020-12-01
D · Potential for more than minimal harm
2020-10-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-12-01
D · Potential for more than minimal harm
2020-10-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-12-01
D · Potential for more than minimal harm
2020-10-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-12-01
D · Potential for more than minimal harm
2020-10-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-12-01
D · Potential for more than minimal harm
2020-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-12-01
Penalties and ownership
What sits behind the stars
Ownership
Einhorn, Sharon
5% Or Greater Direct Ownership Interest · Individual
Friedman, Devorah
5% Or Greater Direct Ownership Interest · Individual
Minzer, Israel
5% Or Greater Direct Ownership Interest · Individual
Einhorn, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Alexander, Sheela
Operational/Managerial Control · Individual
Alsafadi, Soha
Operational/Managerial Control · Individual
Zarcone, Valerie
Operational/Managerial Control · Individual
Zucker, Yossie
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
The Emerald Peek Rehabilitation And Nursing Center
Peekskill, NY
3-star overall rating with 2-star inspections with $139,425 in total fines with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
North Westchester Restorative Therapy & Nrsg Crt
Mohegan Lake, NY
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Yorktown Rehabilitation & Nursing Center
Cortlandt Manor, NY
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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