Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Courtland, Llc during CMS and state inspections, most recent first.
Sewage water backed up into the kitchen, dishwashing area, utility hallway, clean linen room, laundry areas, and a food storage room. Surveyors observed overflowing drains, foul odors, fecal matter near a drain, mattresses sitting in sewage water, and uncovered clean linens and dishes exposed to the contamination while kitchen and laundry activities continued.
A GNA was observed by staff engaging in inappropriate physical contact with a resident, including touching the resident's vaginal area and kissing the resident on the lips. The resident confirmed the contact was consensual and requested, but facility policy prohibits any romantic or sexual involvement between staff and residents. The incident resulted in a deficiency for failure to protect the resident from abuse.
Surveyors found that the facility did not notify the Ombudsman of resident transfers, failed to provide written bed hold policy notices to responsible parties during hospitalizations, and did not supply discharge instructions to a resident with complex medical needs after rehabilitation. These deficiencies were confirmed through record review and staff interviews.
A resident was prescribed a continuous glucose monitoring device to avoid painful finger sticks, but the device was discontinued after a short period without a facility policy in place. The Medical Director informed the provider that the device could not be used, but there was no formal or documented education for staff or providers, and no policy or procedure was developed regarding the use or non-use of such devices.
Failure to involve a resident's representative in vaccine consent. A resident with documented incapacity had a spouse listed as the surrogate, and while the spouse provided telephone consent for the prior flu season, the next flu consent form incorrectly showed the resident as the consenting party with the resident's signature. The RCDO confirmed the spouse should have been contacted instead of the resident.
Failure to provide a reasonable accommodation for a resident’s breakfast needs. A resident’s bed controls were not working, preventing the head of the bed from being raised for eating. A GNA told the resident to wait to eat until upright for safety, and the resident remained in bed with the meal tray untouched until staff later wheeled the resident to a chair and delivered the reheated meal more than 35 minutes later.
A resident admitted for rehab after a stroke and G-tube placement had an abdominal binder applied before consent was obtained. The restraint consent form was completed later, but it did not document the treatment or symptom, the ordering provider, or the potential benefits and risks, and the RN UM acknowledged the consent was not completed timely or appropriately.
Incomplete Investigation of Resident-to-Resident Abuse: Staff failed to complete a thorough investigation after a resident-to-resident assault. The ED’s review relied on limited interviews and did not include statements from the RN assigned to both residents or the shift supervisor who received the report. Staff did not identify the two nurses who responded, and the investigation did not determine what the assaulted resident was doing before the incident, who last saw the resident, or whether there were warning signs or behaviors leading up to the event. No RCA was conducted.
Failure to revise a person-centered care plan for significant wt gain: A resident with mitochondrial metabolism disorders, seizure disorder, anxiety, and depression gained wt from 205 lbs to 257.3 lbs (BMI 41). Staff documented clinically significant wt gain and family agreement to limit sweets, but no measurable wt-control plan, physician report, or revised care plan was completed; the resident was also observed eating cake and drinking juice and expressed distress about her wt and depression.
Oxygen equipment was not consistently labeled for a resident receiving 2 L via NC. Staff observed that the humidifier water bottle and nasal cannula tubing lacked a change date/time, and the tubing was later seen again without labeling. An LPN stated the tubing and humidifier should be labeled each time they are changed, and a UM agreed the tubing should have the change date/time and nurse initials.
The attending physician failed to fully review a resident’s care at required visits and documented that the resident was receiving Tacrolimus on readmission even though the med was never reordered. The resident, who had been admitted for rehab after hospitalization and needed med management for immunosuppressants including Cellcept and Tacrolimus, did not receive Tacrolimus from readmission until discharge. The physician later acknowledged the med should have been on the readmission orders and was missed.
A resident had three cardiovascular meds ordered with hold parameters based on BP and HR, including amlodipine, metoprolol, and hydralazine. The MAR showed the meds were administered for 7 straight days without BP or HR documented, even though the DON stated that vitals should be taken and recorded at the time of administration when parameters are ordered.
Failure to follow diet orders and provide adequate meal portions for a resident with dysphagia and ESRD on HD. The resident repeatedly finished meals and stated they were hungry and had not been given enough food; staff said this had been ongoing, and the RD was unaware that the large-portion order had been discontinued. Nursing staff reported the resident asked for more food every meal, while the resident’s renal product drink and HS snack were also not continued.
Incomplete documentation of resident property and behavior monitoring: Staff failed to document the disposition of a resident’s personal wheelchair and other belongings at discharge, and failed to complete behavior monitoring records for a resident involved in a resident-to-resident abuse incident. The record showed behavior orders for scratching, kicking, wandering, pacing, hitting/punching, and refusal of care, but the relevant shift documentation was blank or incomplete.
Infection control practices were not maintained in the laundry area. A clean linen closet door was observed open with linens uncovered, and two laundry carts in the clean laundry room were left uncovered and exposed to sewer water on the floor. On a later observation, the linen closet door was again open with linens uncovered, and a mobile linen cart in the hallway had exposed linen with the cover draped over the top. Staff stated that the cart should be covered, but staff sometimes forget to cover the linens after getting supplies.
A resident refused flu and PCV 20 vaccines, but the medical record did not document the reason for the refusals even though the forms requested it. The influenza form was signed by the resident and did not note that the refusal was due to the recently ending flu season. An RCDO confirmed that the rationale for refusal should be documented in the resident’s medical record.
Sewage Backup Contaminated Kitchen, Laundry, and Hallway Areas
Penalty
Summary
The facility failed to provide a safe, sanitary environment because sewage water backed up into multiple areas of the building, including the kitchen, dishwashing area, utility hallway, clean linen room, laundry areas, and a food storage room. At the entrance conference, the Nursing Home Administrator confirmed the facility was dealing with a drainage pipe problem and a sewage issue. In the kitchen, surveyors observed pooling sewer water over a floor drain, four other floor drains filled with liquid, and three drains with brown-colored liquid and a foul odor. The kitchen manager stated that the drain by the three-compartment sink had started backing up the day before and that water was being continuously evacuated by floor cleaning machines while the kitchen remained in use. In the dishwashing area, the drain below the dishwasher was overflowing with discharged water, and kitchen staff stated that when drains are clogged, water accumulates until the clog is removed. Clean dishes were observed drying on racks near the dishwasher, and the kitchen manager stated she would cover the clean dishes with plastic. The surveyor also observed dishes on a lower rack less than 6 inches off the floor. In the utility hallway adjacent to the kitchen, sewage was flowing from a drain, fecal matter was next to the drain on the floor, and two mattresses were on the floor in at least one inch of sewage water. A food storage room connected to the hallway had carpet saturated by sewage water, although food items were stored on shelves. The surveyor also observed sewage water on the floor of the clean linen room while laundry was being dried and folded. Two carts of freshly folded laundry were left uncovered and exposed to the sewage water on the floor, and a closet-like area with folded linen had pooling water on the floor with the linen uncovered. In the hallway outside a resident room, a floor drain cover had been removed and a foul odor was noted coming from the drain. Brown substance was also observed being tracked down the hallway from the drain that was overflowing in the front entrance area into the residential hallway.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
A deficiency was identified when a Geriatric Nursing Assistant (GNA) was observed by another GNA and a Registered Nurse (RN) engaging in inappropriate physical contact with a resident. The staff members witnessed the GNA touching the resident's vaginal area and kissing the resident's breast. During subsequent interviews, the accused GNA stated that the resident had requested the application of barrier cream to the vaginal area due to itching, which the GNA did, and denied kissing the resident's breast but admitted to kissing the resident on the lips. The resident confirmed that they had initiated physical contact and consented to the actions, specifically requesting the application of cream, and denied that the GNA kissed her breast but acknowledged a kiss on the lips. Facility policy prohibits employees from becoming romantically or sexually involved with residents. The incident was reported and reviewed, and the GNA involved was later terminated for violating the facility's Standard of Conduct Policy. The deficiency was cited as the facility failed to ensure that the resident remained free from abuse, as required by regulations and facility policy.
Failure to Notify Ombudsman, Provide Bed Hold Policy, and Discharge Instructions
Penalty
Summary
Surveyors identified that the facility failed to notify the Ombudsman of resident transfers and did not provide written notice of the facility's bed hold policy to residents or their representatives upon transfer to the hospital. Specifically, for two residents who were hospitalized, there was no documentation that the Ombudsman was informed of their transfers, and no evidence that the bed hold policy was communicated in writing to their responsible parties. Interviews with the Regional Clinical Director confirmed that, during the relevant period, the facility was not providing these required notifications or documentation. Additionally, the facility failed to provide discharge instructions to a resident and their family upon discharge after rehabilitation for deconditioning and medication management following a kidney transplant. The resident had complex care needs, including gastrostomy tube feeding, wound care, and anti-rejection medications, yet there was no documentation of discharge planning or instructions provided at the time of discharge. The absence of this documentation was confirmed by the Regional Clinical Director during the survey.
Lack of Policy and Oversight for Continuous Glucose Monitoring Device Use
Penalty
Summary
The facility's Medical Director failed to ensure the adequate implementation of resident care interventions and policy review regarding the use of a continuous glucose monitoring device for a resident. Upon admission, the resident was prescribed a continuous glucose monitoring device to monitor blood glucose levels without finger sticks, which the resident preferred due to pain in the fingertips. However, the device was discontinued shortly after being ordered, despite the resident and family expressing dissatisfaction with reverting to finger sticks. Medical record review confirmed the device was ordered and used for approximately 2.5 days before being removed. Interviews with facility staff revealed that there was no existing policy for the use of continuous glucose monitoring devices, as the facility typically associated such devices with home settings. The Medical Director communicated to the provider that the device could not be used in the facility, but there was no formal or documented education provided to staff or other providers regarding this decision. Additionally, there was no documentation of a policy or procedure being developed for the use or non-use of such devices, nor any formal education following the Medical Director's awareness of the device's use in the facility.
Failure to Involve Resident Representative in Flu Vaccine Consent
Penalty
Summary
The facility failed to provide a resident's representative the right to be involved in the vaccination consent process for one resident. Record review showed that the resident had two physician certifications of incapacity, dated 7/21/22 and 8/4/22, both stating the resident was unable to make a rational evaluation of the burdens, risks, and benefits of treatment or a course of treatment. The resident's spouse was listed on the Surrogate Identification Form. For the 2022 flu season, telephone consent for the influenza vaccination was obtained from the spouse, but for the 2023 flu season the consent form indicated the resident gave consent and contained the resident's signature, even though the resident had been documented as unable to provide informed consent. During interview, the Regional Clinical Director of Operations confirmed the spouse should have been contacted for consent for the 2023 flu vaccination instead of the resident.
Failure to Provide Reasonable Accommodation for Breakfast
Penalty
Summary
The facility failed to provide a resident with a reasonable accommodation of need when Resident #77’s bed controls were not working and the resident could not raise the head of the bed to eat. The resident stated the bed had stopped working the prior evening and had occasionally stopped working before. A GNA was aware of the malfunction and told the resident to wait to eat until he or she could be set upright for safety concerns, and later stated the plan was to get the resident up to a chair for breakfast and find another staff member to help. During the observation, the resident remained in bed with the meal tray on the over-the-bed table and had not eaten, and breakfast was not delivered until the resident was wheeled to the activities room more than 35 minutes later after the food was reheated.
Improper Consent and Documentation for Abdominal Binder
Penalty
Summary
The facility failed to acquire and document the appropriate consents and procedures before implementing a restraint for Resident #165. The resident was admitted for rehabilitation after an acute hospital stay in which a gastrostomy tube was placed following dysphasia after a stroke, and an abdominal binder was added to the resident’s care plan on 9/13/23. However, record review showed the abdominal binder had been placed as early as 9/1/23, before consent was obtained. Review of the Physical Restraint/Siderail Consent Form showed that consent for the abdominal binder was not obtained from the family until 9/18/23. The consent form also required documentation of the treatment or symptom for which the restraint was being used, the healthcare provider who ordered it, and the potential benefits and risks, but these items were not identified for Resident #165. During interview, the RN Unit Manager acknowledged that the consent was not completed timely and was not filled out appropriately, and the concern was reviewed with the DON.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to conduct a thorough investigation of a resident-to-resident abuse incident involving Resident #176 and Resident #175. The incident was reported as occurring when Resident #175 assaulted Resident #176 while Resident #176 was lying in bed. The Executive Director stated the incident was reported and investigated, but the investigation relied on interviews conducted by the ED and did not include statements from the RN assigned to both residents at the time of the incident or from the nursing shift supervisor to whom the incident was immediately reported. The Housekeeping Supervisor reported hearing screaming, entering the room, and seeing Resident #175 strike Resident #176, then sending Resident #175 out of the room and notifying two nurses who came to the room and escorted Resident #175 away. The investigation also did not include meaningful statements from the GNAs assigned to each resident, who only stated they did not witness the incident, and five other staff working at the time also only stated they did not witness it. The investigation did not attempt to determine how the incident occurred, including who last saw Resident #176, what the resident was doing, where the resident was, the resident’s behavior or mood, any warning signs, or staff interactions before the incident. The two nurses who were said to have come to the room were not identified and did not provide statements about pre- or post-incident behaviors or interventions. A Regional Director of Clinical Operations confirmed that no RCA was conducted, and the ED was informed of these concerns.
Failure to Revise Care Plan for Significant Weight Gain
Penalty
Summary
The facility failed to develop and revise a comprehensive person-centered care plan with measurable objectives, an ideal healthy weight, and timeframes to address a resident’s significant weight gain. Resident #64 was admitted with diagnoses including mitochondrial metabolism disorders, seizure disorder, anxiety, and depression, and her weight increased from 205 lbs on admission to 229 lbs by November 2024 and then to 257.3 lbs with a BMI of 41 by 6/22/25. During a rounding, the resident stated she wanted to lose some weight and was observed wearing oversize clothes and appearing too small. She also stated she had returned from an emergency room visit after a mental melt-down episode, felt depressed, wanted to kill herself, and felt bad about being unable to do anything for herself except getting bigger. Record review showed Nutrition/Dietary staff documented clinically significant weight gain and noted a regular texture diet, but the care plan only addressed avoiding significant weight change and later family agreement to limit concentrated sweets and starchy foods. Staff documented weight gain of 11.2% in 180 days and noted no specific weight control plans. The resident was observed finishing two layers of cake and drinking juice from her tray. Staff #17 and Staff #16 stated they recognized the significant weight gain but could not explain why no further assessment or weight control was done, and both confirmed they did not report the issue to the physician or revise the person-centered care plan to address the resident’s weight control and psychosocial needs.
Oxygen Equipment Not Labeled
Penalty
Summary
The facility failed to follow its standard of oxygen care consistently for Resident #12, who was admitted after a complicated hospitalization with diagnoses including a new seizure disorder, heart attack, hypoxia, dysphagia, intellectual disability, and end-stage renal disease on hemodialysis MWF. During observation, the resident was found on 2 liters of oxygen via nasal cannula, but there was no label on the humidifier water bottle or on the oxygen nasal cannula tubing showing a change date and time. The resident’s record showed an oxygen order to continue 2-liter nasal cannula oxygen and check every shift, and the facility’s Respirator Therapy of Oxygen Equipment Changing Schedule required newly labeled equipment displaying the date, time, and nurse’s initials. On a later observation, the resident was again noted to be receiving oxygen via nasal cannula, and the tubing still was not labeled with a change date/time. Nursing staff stated that each time the oxygen tubing and humidifier pre-filled with sterile water are changed, both should be labeled, and a Unit Manager observed and agreed that the tubing should have the change date/time and the nurse’s initials.
Physician Failed to Reorder Tacrolimus After Readmission
Penalty
Summary
The attending physician failed to review the resident’s full program of care at each required visit and did not ensure that medication orders and progress notes were accurate for Resident #161. The resident was initially admitted for rehabilitation after hospitalization and required medication management, including Cellcept and Tacrolimus, which are immunosuppressant medications used in organ transplant recipients to prevent rejection. After abnormal labs, the resident was sent to the hospital on 7/8/24 and then readmitted to the facility on 7/18/24. Although the attending physician documented in progress notes that the resident was receiving Tacrolimus on readmission, the medication was never reordered, and the resident did not receive Tacrolimus from readmission until discharge. During interview, the physician acknowledged that the resident should have been on the medication at readmission and that it was missed on the readmission orders.
Unnecessary Medication Regimen and Missing Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary medication without adequate monitoring. Resident #14 had three cardiovascular medications ordered with administration parameters based on blood pressure and/or heart rate: amlodipine besylate 10 mg daily for hypertension with instructions to hold for systolic blood pressure less than 110, metoprolol succinate ER 25 mg daily for CHF with instructions to hold for heart rate less than 60, and hydralazine HCL 25 mg twice daily for hypertension with instructions to hold for blood pressure less than 110 or heart rate less than 60. The resident’s July blood pressure and pulse documentation showed several recorded vital signs, including readings of 163/80 with pulse 83, 130/67 with pulse 88, 126/64 with pulse 77, 128/64 with pulse 74, 134/66 with pulse 78, and 112/58 with pulse 97. During review with the DON, it was stated that the resident had an order for monthly vital signs, and that when medications have parameters, blood pressure and heart rate should be taken and documented so staff can determine whether to administer the medications. The July MAR showed that the medications were given for 7 consecutive days without blood pressure or heart rate documented in the medical record. The DON stated that any vitals taken to evaluate whether the medications should have been given should have been documented at the time of administration.
Failure to Follow Diet Orders and Provide Adequate Meal Portions
Penalty
Summary
The facility failed to track proper diet orders, process repeated requests for insufficient meal portions, and honor a resident’s right to meet personal dietary proportion needs. Resident #12, who was admitted after a complicated hospitalization with new diagnoses of seizure disorder, heart attack, hypoxia, dysphagia, and end-stage renal disease on hemodialysis, had an admission diet order of pureed renal texture. The resident’s nutritional assessment documented a weight of 160.6 lbs and a 9.2% weight loss compared with the pre-hospitalization weight. The resident’s weight log showed 167.42 lbs on 01/23/2025 and 163.79 lbs on 06/09/2025. The resident also had large portion meals, a renal product drink, and a before-sleep snack ordered on 04/29/2025, but these were discontinued when the resident was hospitalized on 06/05/2025. During observation, the resident finished the lunch tray and yelled that they were hungry and had not been brought enough food; a GNA stated that she had notified the kitchen for additional food and that this had been ongoing for a while. On another observation, the resident’s breakfast tray was completely finished, and later the resident again yelled that they were hungry and needed food. The resident’s meal consisted of three parts of thin watery pureed food. The dietitian stated she was not aware of the resident’s complaints about insufficient meal portions or that the large portions order had been discontinued. Nursing staff stated the resident was always hungry and asked for more food every meal since readmission. After surveyor intervention, the large portion meal was reordered, but the renal product drink and before-sleep snack were not.
Incomplete documentation of resident property and behavior monitoring
Penalty
Summary
Facility staff failed to maintain complete and accurately documented medical records for a discharged resident’s personal property. Resident #163’s record showed a personal inventory list that included a wheelchair listed as acquired after admission, and staff interviews indicated the resident likely had a wheelchair while in the facility. However, the record did not document whether the wheelchair was the resident’s property or the facility’s, and there was no documentation showing the disposition of the resident’s belongings at discharge, including who received them or when they were released. Facility staff also failed to document resident behavior for a resident involved in a resident-to-resident abuse incident. Resident #176 had physician orders for behavior monitoring for scratching, kicking, wandering, pacing, hitting/punching, and refusal of care, and the March 2023 behavior record had spaces for these behaviors. For the shift when the incident occurred, the evening shift record showed all behaviors as not occurring except wandering, which was left blank, and the night shift record contained no behavior documentation. Staff interviews confirmed the incident occurred, but staff could not recall or explain the resident’s behaviors at the time, and the facility acknowledged the lack of behavior documentation for that shift.
Infection Control Failure in Laundry Area
Penalty
Summary
The facility failed to maintain infection prevention and control practices in the laundry area. On 7/15/25 at 10:51 AM, the surveyor observed the clean laundry room with the door to a linen closet open and linens not covered. Two carts in the clean laundry room, where staff had just folded and placed laundry, were left uncovered and exposed to sewer water on the floor. Staff #1 stated that all linens would be re-washed and the room terminally cleaned after this was brought to his attention. On 7/18/25 at 10:51 AM, the surveyor again observed the linen closet door open with linens not covered. Laundry Staff #40 stated that the clean laundry bin in the closet was preventing the door from closing, but that she would be folding the linens next and, after the bin was removed, the door would be closed. In the hallway, a mobile laundry cart was observed with linen exposed and the cover draped over the top of the cart. Staff #40 stated that the linen cart should be covered but that staff sometimes come down to get linen and forget to cover the linens after obtaining their supplies.
Failure to Document Rationale for Vaccine Refusal
Penalty
Summary
The facility failed to document the rationale for non-administration of the influenza and pneumococcal immunizations for one resident reviewed for vaccinations. Record review showed that the resident refused all vaccinations offered on 4/4/25, and the influenza vaccination form documented that the resident declined the flu vaccine but did not include the reason for refusal even though the form requested it. The form was signed by the resident and did not state that the refusal was due to the recently ending flu season. Review of the pneumococcal conjugate vaccine (PCV 20) form also showed that the resident declined the vaccine, but no rationale for the refusal was documented. During interview, the Regional Clinical Director of Operations confirmed that the rationale for refusal should be documented in the resident's medical record.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,786 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Pikesville | 1.5 mi | ★★★★★ | 0 | 0 |
| North Oaks Communities | 1.6 mi | ★★★★★ | 13 | 0 |
| Resorts Of Augsburg | 1.7 mi | ★★★★★ | 40 | 0 |
| King David Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 22 | 0 |
| Future Care Old Court | 1.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Courtland, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.