Yorktown Rehab: Fall Risk Resident Left Alone - NY
That sequence of events is what federal inspectors documented during a complaint investigation completed August 28, 2025.
The aide, identified in the inspection report only as Certified Nurse Aide #1, was assigned to the resident for the first time that shift. It was their first time providing care to Resident #1. They had been told during shift report, by both another aide and a licensed practical nurse, that the resident was a fall risk.
Because of that risk, the aide made Resident #1 the first resident they attended to that morning. They got the resident up, handed them a call bell and a urinal, locked the wheels on the wheelchair, and left.
Then they distributed breakfast trays to other residents on the unit.
Thirty to forty minutes passed.
The aide heard a commotion. They went to Resident #1's room and found the resident on the floor.
After providing care, the aide wheeled Resident #1 out to the nurses' station. The nurse told them the family doesn't like that. Wheel the resident back into their room.
The aide did.
Certified Nurse Aide #1 told inspectors they understood the standard practice on the unit: residents who are fall risks are kept near the nurses' station so staff can watch them. The family of Resident #1 had made a different request. They did not want their family member parked outside the nurses' station. They wanted the resident left in their room.
The inspection report does not say whether anyone at the facility had documented this request, whether it had been weighed against the resident's fall risk, or whether any plan had been put in place to compensate for the reduced supervision. It does not say whether the aide or the nurse raised a concern before leaving the resident alone again after the fall.
What the report says is that a known fall-risk resident was left unobserved for up to forty minutes, fell, and was then returned to the same unsupervised setting.
The violation was cited under the tag for accident hazards and supervision, with inspectors finding the facility failed to provide adequate supervision to prevent the fall. The level of harm was assessed as minimal harm or potential for actual harm. A few residents were identified as affected.
The tension at the center of this case is a familiar one in nursing home care: a family's wishes running up against a resident's safety needs. Families have real authority over care decisions. They can refuse certain interventions. They can request that a loved one be kept in their room rather than parked in a hallway outside a busy nursing station, which is a reasonable human preference. Nursing homes are required to honor those preferences where they can.
But that accommodation requires something in return. If the standard safety net, keeping a fall-risk resident visible to staff, is removed, something else has to fill the gap. More frequent check-ins. A different monitoring approach. Some documented alternative.
The inspection report contains no indication that any alternative was in place. The aide handed the resident a call bell, locked the wheels, and left to distribute breakfast trays. Forty minutes later, the resident was on the floor.
Yorktown Rehabilitation & Nursing Center is a skilled nursing facility in Westchester County. The complaint inspection that produced this finding was completed in late August 2025.
The resident's name was not included in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Yorktown Rehabilitation & Nursing Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 30, 2026 · Our methodology
YORKTOWN REHABILITATION & NURSING CENTER in CORTLANDT MANOR, NY was cited for violations during a health inspection on August 28, 2025.
That sequence of events is what federal inspectors documented during a complaint investigation completed August 28, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.