Cortlandt Healthcare

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (2632359) the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 (one) of 3 (three) residents (Resident #1) reviewed for falls. Specifically, Resident #1's care plan was not updated after a fall on 7/18/2025 to reflect a new intervention until 07/21/2025. The 09/18/2025 Facility Falls-Clinical Protocol policy documented the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will identify pertinent interventions to try to prevent subsequent falls. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 2/25/2025 to 3/3/2025, the facility did not ensure infection prevention was maintained. This was evident for 1 (1st Floor) of 3 resident units. Specifically, Housekeeper #3 was observed in a contact/droplet precaution room without the required personal protective equipment.

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (NY00351622), the facility did not ensure timely removal of discontinued medications from the narcotic cabinet. This was evident for 1 (Resident #1) out of 3 Residents reviewed for medications. Specifically, Resident #1's Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg-controlled medication was discontinued as per prescriber's order on 07/11/2024. The controlled medication remained in the medication cabinet/room and narcotic records were still available from 7/11/2024 to 8/18/2024. On 8/18/2024 Licensed Practical Nurse #10 accessed and administered the discontinued controlled medication to Resident #1 without a prescriber's order.

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (NY00351622), it was determined that the facility did not ensure residents were free from medication errors. This was evident for 1 (Residents #1) out of 3 residents reviewed for medication administration. Specifically, Licensed Practical Nurse #10 administered a Narcotic Drug Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg 1 tablet to Resident #1 without an order on 08/18/2024.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted from 10/12/23 to 10/20/23, the facility did not ensure that each resident had the right to make choices about aspects of their life in the facility that were significant to the resident for 1 of 3 residents (Resident #21) reviewed for choice. Specifically, Resident #21 was not provided a choice regarding whether to receive a bed bath or shower and the resident was not provided the opportunity to participate in activities they enjoyed including going to the public library.

Inspectors wroteBased on interview and record review conducted during the recent recertification survey, the facility did not ensure for 1 of 2 residents (#61) reviewed for hospitalization that the resident or resident's representative were notified in writing of transfer/discharge to the hospital, including the effective date of transfer, location of transfer, and reason for transfer.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure that to the extent practicable, each resident was offered the opportunity to participate in their plan of care, or that an explanation was included in a resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan for 2 (Residents #46 and #39) of 3 residents reviewed for care planning. Specifically, Residents #46 and #39 expressed interest in attending care planning meetings and reported they had not been invited.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure all residents were provided the necessary care and services for 1 of 3 residents (Resident #39) reviewed for activities of daily living (ADL). Specifically, Resident #39, who had a diagnosis of aphasia (a loss of ability to understand or express speech, caused by brain damage), was not assessed and treatment was not provided to enable the resident to communicate with others more normally including speech and/or other functional communication systems.

Inspectors wroteBased on observations, record review and interviews, during a recertification survey from 10/12/23-10/20/23, the facility did not ensure the resident environment remained free of accident hazards to prevent accidents for 1 (Resident #28) of 6 residents reviewed for accidents. Specifically, Resident #28, who was assessed as needing a bed rail to promote independence, had the rail removed and when they awoke from a nap and reached for the rail, they fell and sustained a fractured (broken) shoulder and blunt head trauma.

Inspectors wroteBased on observations, interviews and record review conducted during the recent recertification survey, the facility did not ensure that emergency equipment was readily available for 1 of 2 residents (Resident #35) screened for respiratory care. Specifically, a resident with a tracheostomy did not have an Ambu bag (a hand-held device that provides positive pressure to residents who are not breathing) at the bedside.

Inspectors wroteBased on record review and interview conducted during the recertification abbreviated surveys (NY00322999) from 10/12/2023 to 10/20/2023, the facility did not ensure that an allegation of resident neglect was fully investigated. This was evident for one of two residents (Resident #372 ) reviewed for abuse. Specifically, when it was alleged that Resident #372 was left in a chair for two shifts, including over night, the facility did not conduct a thorough investigation to rule out neglect and did not report the allegation to the New York State Department of Health (NYSDOH).

Inspectors wroteBased on observations, interviews and record review conducted during a recertification survey the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented to meet the resident's medical, physical, mental and psychosocial needs. Specifically, 1) a care plan was not developed for 1 of 3 residents (#53) reviewed for range of motion (ROM), and 2) the care plan was not implemented as per physician's orders for 1 of 4 residents (#35) reviewed for respiratory care.

Inspectors wroteF919 Based on observation, record review and interview conducted during a recertification survey, it could not be ensured that the facility maintained the resident call bell system in proper working order. Specifically, the call bell system on the 1st floor was unable to be heard clearly at the nurses' station when the call bells were activated from residents' rooms.

Inspectors wroteF657 Based on record review and interview conducted during a recertification survey, it cannot be ensured that the facility reviewed and revised Comprehensive Care Plans with measurable objectives, timeframes and appropriate interventions for 1 of 1 residents (#44) reviewed for prevention of further decline and/or potential restoration of urinary continence to the extent possible.

Inspectors wroteF686 Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility reviewed 1 of 4 residents (#23) for pressure ulcer or provided the appropriate care to promote healing of an existing pressure ulcer and prevent further pressure ulcers. Specifically, bilateral heel booties were not applied at all times as per physician orders.

Inspectors wroteF690 Based on interview and record review conducted during a recertification survey, it could not be ensured that the facility provided the necessary care to promote and maintain bladder continency to the extent possible for 1 of 1 residents (#44) reviewed for urinary incontinence. Specifically, the type of urinary incontinence was not identified and a Patient-Centered Care Plan, based on the type of incontinence and maintenance versus restorative goals and interventions, was not developed.

Inspectors wroteF695 Based on observation, record review and interview conducted during a recertification survey, it cannot be ensured that the facility provided care consistent with professional standards for 1 of 4 (Resident #35) reviewed for respiratory care. Specifically, for Resident #35, the facility did not ensure the Physician's Order for the prescribed oxygen administration was followed.

Inspectors wrotePressure Ulcer/Injury F880 Based on observation, interview, and record review conducted during a recertification survey, it could not be ensured that facility staff followed proper hand hygiene during wound care treatment for 1 of 4 residents (Resident #23) reviewed for pressure ulcers.