Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crown Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with diabetes, cellulitis of the left great toe, and prior sacral pressure ulcer history developed a new sacral pressure injury that was first noted by a CNA and assessed by an RN, who cleansed the area and applied a foam dressing but did not document the finding or notify a provider. On the following shift, a CNA again observed a reddened sacral area and a soiled, detached dressing, and an LPN applied a new foam dressing and notified an off-duty RN manager by text instead of the on-site supervisor, and did not contact a provider. Only later, when another LPN reported a change in condition including severe hyperglycemia, did an RN supervisor remove the dressing, find a foul-smelling sacral wound with gray-brown drainage, and notify the on-call provider, who ordered transfer to the ED, where the wound was identified as an unstageable/stage 3 sacral pressure ulcer requiring packing.
A resident with atrial fibrillation and a mechanical heart valve was not properly monitored for anticoagulation therapy, as required weekly PT/INR testing was missed and the diagnosis was not documented in the medical record or care plan. The provider was not notified of the missed lab, and the resident subsequently suffered an acute stroke due to subtherapeutic INR levels.
The facility failed to maintain the left walk-in cooler at safe temperatures, with food items measuring between 45 and 54 degrees Fahrenheit. The staff lacked proper procedures and knowledge for temperature monitoring, leading to the discarding of several food items. The Regional Food Service Director acknowledged the risk of bacterial growth and foodborne illness due to improper storage.
The facility failed to maintain a safe, clean, and homelike environment in several units, with issues such as missing paint, unpainted patched holes, and missing door thresholds creating tripping hazards. Dirty linens and personal items were found on floors, and the dining room lacked homelike decorations. Staff interviews revealed a lack of awareness and action in addressing these issues, despite a computerized work order system in place.
The facility failed to properly label and store medications, with multiple instances of medications lacking opened or expiration dates on two medication carts and one storage room. An LPN acknowledged the issue, stating that without proper labeling, the effectiveness of medications could not be guaranteed. Additionally, a medication cart was found unlocked and unattended, violating facility policy.
The facility failed to provide residents with food and drink at palatable and safe temperatures during two observed lunch meals. Residents reported dissatisfaction with the food quality, noting it was often lukewarm and lacked variety. Staff confirmed that food temperatures did not meet the facility's policy requirements, posing a risk of bacterial growth.
The facility failed to maintain food safety standards in the main kitchen, with issues such as unprotected food in the walk-in freezer, inadequate lighting protection, and unclean surfaces. Observations included an uncovered box of hamburgers, exposed wiring, and broken floor tiles. Interviews revealed lapses in cleaning protocols and long-standing maintenance issues.
A facility failed to maintain an effective infection prevention and control program, as evidenced by improper storage of a urinary drainage bag for a resident and a non-functional sink in a medication room. The resident's catheter drainage bag was observed on the floor, contrary to policy, risking infection. Staff interviews confirmed the importance of keeping the bag off the floor. Additionally, the medication room sink was non-functional, compromising hand hygiene. Maintenance records showed unresolved issues, highlighting deficiencies in infection control practices.
The facility failed to inform residents about the grievance process and did not promptly address grievances related to long call bell wait times. Nine residents were unaware of the grievance official, and ongoing complaints about call bell delays were documented but not resolved. Observations showed call bells going unanswered for extended periods, and staff interviews confirmed the issue was known but unresolved.
A resident with Parkinson's Disease and other conditions requiring substantial assistance with oral hygiene did not receive necessary oral care, as observed during a survey. Despite being cognitively intact, the resident reported not receiving oral care on multiple occasions, leading to a dry mouth and a thick white substance on their mouth and tongue. The facility's policy required oral care to prevent infections, but this was not followed, resulting in a deficiency.
Failure to Assess and Notify Provider for New Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and its own policies when a resident developed a new sacral pressure ulcer. The resident had multiple diagnoses including type 2 diabetes mellitus with complications, cellulitis of the left great toe, and a history of a stage 3 sacral pressure ulcer. Admission and subsequent assessments documented intact skin, and the care plan included weekly skin checks, incontinence management, pressure-reducing devices, and other skin integrity interventions. Prior to the incident, there were no physician orders for pressure ulcer treatment, and the resident was documented as not having unhealed pressure ulcers and not being at risk for pressure ulcers on the most recent MDS, despite other documentation indicating they were at risk. On the night shift of 12/26–12/27, a CNA observed a skin issue on the resident’s sacrum and notified an RN, who assessed the area as red and quarter-sized, cleansed it with normal saline, and applied a foam dressing. The RN did not document this assessment in the nursing progress notes and did not notify a medical provider, contrary to facility policy requiring assessment and physician notification for changes in condition. The RN reported the issue only to the oncoming nurse at shift change. The following day, a CNA on day shift again observed a reddened area on the sacrum and a soiled, detached dressing in the resident’s incontinence brief, and notified an LPN. The LPN applied a clean foam dressing and notified an off-duty RN unit manager by text, rather than the in-house nursing supervisor, and did not contact a medical provider. The RN unit manager, who was not in the building, instructed that a progress note not be written until an RN assessed the area, and no further direction was given. Later that same day on evening shift, another LPN reported to the RN supervisor that the resident had a change in condition, including a blood sugar of 504 and a pressure area on the sacrum. Upon removing the foam dressing, the RN supervisor found the sacral wound to be foul-smelling with gray and brown drainage and documented low oxygen saturation and an elevated temperature. The on-call medical provider was then notified and ordered the resident sent to the emergency department. Hospital documentation later identified the sacral wound as an unstageable pressure ulcer requiring packing and as a stage 3 decubitus ulcer. There was no documented RN assessment or provider notification at the time the sacral wound was first identified or during the subsequent day shift, and no Braden reassessment was completed when the ulcer was discovered, despite facility policy requiring such actions when a new pressure injury or change in condition occurs. Interviews confirmed that the physician assistant who last saw the resident before the ulcer was discovered had not been informed of any skin issues and had observed intact skin at that time. The assistant DON/wound nurse stated they were not notified of the sacral ulcer until the resident was readmitted from the hospital and that a Braden assessment should have been completed when the ulcer was first found. The DON stated that nurses who discover a skin issue are expected to notify the nursing supervisor and medical provider, obtain treatment orders, and, if the nurse is an LPN, ensure an RN assessment occurs or contact leadership if no RN is in the building. The facility’s own investigation concluded that the night-shift RN who first assessed the sacral area did not document the pressure area or notify a medical provider, and that both the night RN and the day-shift LPN failed to follow the required notification chain of command, resulting in a lack of timely assessment and provider notification for the new sacral pressure ulcer.
Failure to Monitor Anticoagulation Therapy and Maintain Therapeutic INR
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation and a mechanical heart valve replacement was admitted to the facility following a hospital stay. The resident was prescribed warfarin therapy and required weekly Prothrombin Time/International Normalized Ratio (PT/INR) monitoring to ensure therapeutic anticoagulation levels, as recommended for individuals with mechanical heart valves. However, the resident's electronic medical record did not document the diagnosis of a mechanical heart valve replacement, nor did it include a provider rationale for not maintaining the INR within the recommended therapeutic range for such patients (2.5-3.5). The facility failed to obtain the resident's PT/INR as ordered on a specific date, and there was no documented evidence that the provider was notified of the missed lab. The facility's policy required prompt reporting of lab values and provider notification if labs were missed, but this did not occur. Additionally, the resident's care plan did not address anticoagulation therapy or the need for monitoring related to the mechanical heart valve, and the diagnosis was omitted from both the diagnosis sheet and care plan. Three days after the missed PT/INR, the resident exhibited impaired speech and increased confusion, prompting transfer to the hospital. At the hospital, the resident was found to have a subtherapeutic INR (1.16) and was diagnosed with an acute stroke. Interviews with facility staff and providers confirmed that the lack of documentation and communication regarding the resident's mechanical heart valve and missed lab contributed to the failure to maintain appropriate anticoagulation, resulting in actual harm to the resident.
Failure to Maintain Safe Cooler Temperatures
Penalty
Summary
The facility failed to maintain the left walk-in cooler in the kitchen at a safe operating temperature, which is a critical requirement for food safety. The cooler was observed to have temperatures above the required 41 degrees Fahrenheit, with food items inside measuring between 45 and 54 degrees Fahrenheit. This discrepancy was noted during a recertification survey, where it was found that the facility did not have a policy or procedure for the preventative maintenance of the walk-in coolers. The Food Service Director and staff were unaware of the exact temperature requirements and did not consistently check the internal temperature of the cooler contents, relying instead on external thermometers that provided conflicting readings. Interviews with the Food Service Director and Dietary Aide revealed a lack of knowledge and adherence to proper temperature monitoring protocols. The staff did not measure the temperature of the cooler contents to verify the accuracy of the thermometer readings, and there was no clear documentation of who recorded the temperatures. As a result, several food items were found to be out of the safe temperature range and were discarded. The Regional Food Service Director acknowledged the importance of maintaining proper food storage temperatures to prevent bacterial growth and potential foodborne illnesses, especially given the vulnerability of the residents due to their underlying health conditions.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in several units, as observed during a recertification survey. Specifically, Units 2 North, 2 South, and 3 South exhibited numerous maintenance and cleanliness issues. These included missing paint, unpainted patched holes, missing door thresholds, missing tiles, and dirty linens on the floors. Additionally, the 2 South dining room lacked homelike decorations. The facility's policies on resident rights and quality of life emphasized the importance of maintaining a dignified and homelike environment, yet these standards were not met. Observations revealed specific deficiencies, such as large areas of missing paint in resident rooms, missing floor tiles, and door thresholds that created uneven surfaces. These issues were compounded by the presence of dirty linens and personal items like empty soda bottles and pizza boxes on the floors, which were not promptly addressed. Interviews with staff, including registered nurses, certified nurse aides, and housekeepers, indicated a lack of awareness and action regarding these environmental issues. Staff members were expected to report maintenance issues through a computerized work order system, but many were unaware of the problems or did not follow through with reporting them. The Director of Housekeeping and Laundry and the Director of Maintenance acknowledged the presence of these issues and the potential hazards they posed, such as tripping hazards from missing thresholds. Despite having a system in place for reporting and addressing maintenance issues, there were multiple open work orders that had not been completed. The facility's failure to maintain a homelike environment was evident in the observations and interviews, highlighting a disconnect between policy and practice in ensuring resident safety and comfort.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, leading to deficiencies in medication management. During the recertification survey, it was observed that two of the five medication carts and one of the three medication storage rooms contained medications without proper labeling of opened or discard dates. Specifically, the 3 North A side cart had multiple medications, including eye drops, insulin pens, and inhalers, without opened or expiration dates. Similarly, the 2 North A side cart had diabetic pens without opened or discard dates, and the 3 North medication refrigerator contained expired vials of influenza vaccine and tuberculin without proper labeling. The facility's policy required that medications be labeled with opened dates and expiration dates to ensure their effectiveness and safety. However, observations revealed that this policy was not consistently followed. Licensed Practical Nurses (LPNs) acknowledged that without opened dates, it was impossible to determine the medications' validity, potentially leading to the administration of ineffective medications. The Registered Nurse Unit Manager confirmed that all multidose medications should be labeled when opened, and expired medications could result in adverse reactions or reduced effectiveness. Additionally, a medication cart on the 3 South B side was found unlocked and unattended in a common resident hallway, contrary to the facility's policy that required medication carts to be locked when not attended. The Director of Nursing emphasized the importance of dating medications when opened and ensuring carts are locked to prevent unauthorized access. The failure to adhere to these protocols resulted in deficiencies in medication management and storage, as identified during the survey.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at appetizing temperatures during two observed lunch meals. On 1/14/2025, a lunch meal on the 1st floor was served with ham at 121.1 degrees Fahrenheit, corn at 113.9 degrees Fahrenheit, and orange juice at 52 degrees Fahrenheit, all of which were outside the facility's policy requirements for safe serving temperatures. Similarly, on 1/15/2025, a lunch meal on the 3rd floor included tuna noodle casserole at 133 degrees Fahrenheit, cooked carrots at 110.8 degrees Fahrenheit, mashed potatoes at 126.9 degrees Fahrenheit, and gravy at 128.5 degrees Fahrenheit, again failing to meet the required temperature standards. These deficiencies were confirmed by staff members, including a Licensed Practical Nurse and a Certified Nurse Aide, who verified the temperatures. Residents expressed dissatisfaction with the food quality, noting that it was not hot, was often lukewarm, and lacked variety. Complaints included burnt grilled cheese sandwiches, tough meat, overcooked noodles, and repetitive menu items like ham. The Director of Activities and Dietary Aide acknowledged recurrent food complaints during Resident Council meetings, emphasizing the importance of serving food at appropriate temperatures to ensure palatability and prevent bacterial growth. The Corporate Regional Director also confirmed that the food temperatures were not acceptable and highlighted the risk of bacterial growth in the temperature danger zone, which could potentially make residents sick.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, it was observed that food in the walk-in freezer was not adequately protected, with an uncovered open box of hamburgers and food and packaging debris under shelving. Additionally, there was ice build-up on the ceiling and an open junction box with exposed wiring. The kitchen lighting was not properly shielded, as most lights lacked protection, and the facility could not confirm if the bulbs were shatter-resistant. The condenser outside of the cooler had dirt and grease build-up, and there were several broken floor tiles in the dry storage room, which were not smooth or easily cleanable. Interviews with the Regional Food Service Director and Kitchen Supervisor revealed lapses in cleaning and maintenance protocols. The Regional Food Service Director emphasized the importance of proper food storage to prevent contamination and stated that the walk-in freezer should be cleaned weekly, but the Kitchen Cleaning log audit for December 2024 and January 2025 was blank. The Kitchen Supervisor was unsure how long the light covers had been missing, indicating a long-standing issue. These deficiencies highlight a failure to maintain a clean and safe kitchen environment, potentially leading to cross-contamination and other food safety hazards.
Infection Control Deficiencies: Improper Catheter Care and Non-Functional Sink
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper storage of a urinary drainage collection bag for Resident #17 and a non-functional sink in the 2 South B medication room. Resident #17, who had severe cognitive impairment and multiple diagnoses including urinary retention and multidrug-resistant organisms, was observed with their urinary catheter drainage bag lying directly on the floor without a barrier. This was contrary to the facility's policy, which required catheter tubing and drainage bags to be kept off the floor to prevent contamination and infection. Interviews with staff, including a Certified Nurse Aide, a Licensed Practical Nurse, and a Registered Nurse Unit Manager, confirmed that the drainage bag should not touch the floor and should be kept in a dignity bag. They acknowledged that the floor was dirty and could lead to a urinary tract infection for Resident #17. Despite receiving training on catheter care, the staff failed to adhere to the facility's policy, resulting in the observed deficiency. Additionally, the sink in the 2 South B medication room was found to be non-functional, with a white substance on the handles, rust, and towels obstructing the basin. The water supply had been shut off, and staff had to use alternative locations for handwashing. Maintenance records indicated that the issue had been reported but not resolved, and the Maintenance Director was unaware of the ongoing problem. The lack of a functional sink compromised the facility's ability to maintain proper hand hygiene, a critical component of infection control.
Failure to Address Grievances and Long Call Bell Wait Times
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process and that grievances were promptly addressed. During a resident group meeting, nine anonymous residents expressed that they were unaware of who the grievance official was or how to file a grievance. They reported ongoing issues with long call bell wait times, which had been a recurrent complaint in monthly resident council meetings. Despite these complaints being documented in meeting notes from July to November 2024, there was no visible information in the facility regarding the grievance officer or accessible grievance forms. Additionally, Resident #446 had filed a formal grievance about the long call bell wait times, which was recorded in the grievance log. Observations during the survey period revealed multiple instances of delayed responses to call bells, with some going unanswered for up to 45 minutes. Interviews with facility staff, including the Director of Activities, the Director of Social Services, and the Director of Nursing, confirmed that long call bell wait times were a frequent issue. The Director of Social Services, who was the grievance officer, acknowledged the problem and stated that investigations were conducted through the formal grievance process. However, despite efforts such as staff education and changes in staff assignments, the facility had not yet found an effective solution to address the issue.
Failure to Provide Necessary Oral Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain oral hygiene. The resident, diagnosed with Parkinson's Disease, stroke, and tremors, required substantial assistance with oral care. Despite being cognitively intact and not rejecting care, the resident reported not receiving oral care on multiple occasions, leading to a dry mouth and the presence of a thick white substance on their mouth and tongue. The facility's policy required oral care to be provided to maintain cleanliness and prevent oral infections, but this was not adhered to. Observations and interviews revealed that the resident did not receive oral care on several days, and the care was not documented in the electronic medical record. Certified Nurse Aide #8 admitted to missing oral care during a bed bath, and both the LPN Unit Manager and RN Unit Manager were unaware of the lapse in care. The resident's care plan specified the need for substantial assistance with oral hygiene, yet the facility failed to provide the necessary support, resulting in a deficiency under 10 NYCRR 412.12(A)(3).
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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.
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Nursing homes near Cortland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cortland Park Rehabilitation And Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Guthrie Cortland Medical Center | 1.5 mi | ★★★★★ | 14 | 2 |
| Groton Community Health Care Ctr Res Care Fac | 10.7 mi | ★★★★★ | 25 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 15.6 mi | ★★★★★ | 14 | 0 |
| Kendal At Ithaca | 18.3 mi | ★★★★★ | 0 | 0 |
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