Cycle 1
Health 2024-01-24 · Fire 2024-01-24
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cortlandt Manor, NY
Yorktown Rehabilitation & Nursing Center
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
2300 Catherine Street, Cortlandt Manor, NY
(914) 739-2244
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
122
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.71
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
471
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0220
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.38% · Performance 16.43% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.98
Baseline 6.09% · Performance 5.75% · Measure score 6.98 · Achievement 6.98 · Improvement 2.58
Total nurse turnover
9.09
Baseline 34.82% · Performance 26.53% · Measure score 9.09 · Achievement 9.09 · Improvement 7.81
Adjusted total nurse staffing
1.63
Baseline 2.94 hours · Performance 3.54 hours · Measure score 1.63 · Achievement 1.63 · Improvement 1.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 7.18% · Lower 95% interval 6.51% |
| Discharge to community | 52.55% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 46% · Lower 95% interval 44.09% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 98.19% |
95.27%
2.9 pts better
|
Numerator 163 · Denominator 166 |
| Falls with major injury | 1.81% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 166 |
| Discharge self-care score | 50.41% |
53.69%
3.3 pts worse
|
Numerator 62 · Denominator 123 |
| Discharge mobility score | 53.66% |
50.94%
2.7 pts better
|
Numerator 66 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 0.6% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 166 · Adjusted rate 0.56% |
| Healthcare-associated infections requiring hospitalization | 5.75% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 3.9% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0.49% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 203 |
| Staff flu vaccination coverage | 41.15% |
42%
0.9 pts worse
|
Numerator 79 · Denominator 192 |
| Discharge function score | 52.85% |
56.45%
3.6 pts worse
|
Numerator 65 · Denominator 123 |
| Transfer of health information to provider | 89.47% |
95.95%
6.5 pts worse
|
Numerator 34 · Denominator 38 |
| Transfer of health information to patient | 96.63% |
96.28%
0.3 pts better
|
Numerator 86 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 35.29% |
25.2%
10.1 pts better
|
Numerator 36 · Denominator 102 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 45.2% |
95.3%
50.1 pts worse
|
95.5%
50.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 45.2% |
| 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 3.7% · Q2 2.5% · Q3 3.4% · Q4 2.5% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.4% |
18.5%
42.9 pts worse
|
11.4%
50 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 62.7% · Q3 50.0% · Q4 56.9% · 4Q avg 61.4% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 5.7% · Q4 10.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
13.5%
1.7 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 15.4% · Q3 11.5% · Q4 7.6% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
14.8%
2.2 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.3% · Q3 12.3% · Q4 10.9% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.7% |
0.2%
2.5 pts worse
|
0.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.7% · Q3 2.2% · Q4 2.5% · 4Q avg 2.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.8% |
15.1%
4.7 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 25.8% · Q3 13.8% · Q4 13.2% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
15.5%
1.1 pts worse
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 22.4% · Q3 6.3% · Q4 12.9% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.6%
0.7 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.3% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
20.8%
9.1 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 35.9% · Q3 26.3% · Q4 29.1% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
6.9%
3.6 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 4.4% · Q4 4.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
76.7%
19 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 95.0% · Q3 96.5% · Q4 96.7% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
9.7%
4.4 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 4.9% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.4% · Q3 2.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
78.8%
6.2 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
20.6%
5.7 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.8% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-10-28 · Fire 2020-10-28
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-10-05 · Fire 2018-10-05
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-13
D · Potential for more than minimal harm
2020-10-28
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2020-12-18
D · Potential for more than minimal harm
2020-10-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-12-18
D · Potential for more than minimal harm
2020-10-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-12-18
E · Potential for more than minimal harm
2018-10-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-12-04
E · Potential for more than minimal harm
2018-10-05
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-12-04
E · Potential for more than minimal harm
2018-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-04
D · Potential for more than minimal harm
2018-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-12-04
D · Potential for more than minimal harm
2018-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-12-04
D · Potential for more than minimal harm
2018-10-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-12-04
C · Minimal harm
2018-10-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-12-04
C · Minimal harm
2018-10-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-12-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-28
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 2025-09-16
D · Potential for more than minimal harm
2024-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-01
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 2024-05-08
E · Potential for more than minimal harm
2024-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-01-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-13
D · Potential for more than minimal harm
2023-06-01
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-08-01
E · Potential for more than minimal harm
2020-10-28
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 2020-12-18
E · Potential for more than minimal harm
2020-10-28
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 2020-12-18
E · Potential for more than minimal harm
2020-10-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-12-18
E · Potential for more than minimal harm
2020-10-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-12-18
E · Potential for more than minimal harm
2020-10-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2020-12-18
D · Potential for more than minimal harm
2020-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-12-18
D · Potential for more than minimal harm
2020-10-28
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 2020-12-18
D · Potential for more than minimal harm
2020-10-28
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2020-12-18
B · Minimal harm
2018-10-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2018-11-01
Penalties and ownership
What sits behind the stars
Ownership
Barth, Alexander
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yechiel
5% Or Greater Direct Ownership Interest · Individual
Walden, Yehudah
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
Corporate Officer · Individual
Dolfo, Keala
Operational/Managerial Control · Individual
Joseph, Josmi
Operational/Managerial Control · 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
Cortlandt Healthcare
Cortlandt Manor, NY
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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