Above 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 Courtyard Gardens Nursing And Rehab Ctr during CMS and state inspections, most recent first.
A resident with impaired cognition, muscle weakness, and decreased mobility had care-planned interventions requiring use of wheelchair footrests when being pushed. On one occasion, an outside transport company pushed the resident in a wheelchair without footrests in place, and the resident’s right foot dropped under the wheelchair, causing immediate discomfort. Later, the resident reported increasing right ankle pain with swelling and warmth, and an NP ordered an x-ray, which revealed a bimalleolar ankle fracture. The DON confirmed the fracture occurred because leg rests were not used during transport.
A resident with chronic medical conditions experienced an ankle injury when her foot went under a wheelchair, after which she repeatedly reported right ankle pain with documented swelling, redness, and later confirmation of a bimalleolar fracture. Staff administered PRN acetaminophen multiple times with little effect and applied an ace wrap and ice, but there was no documentation that a physician was notified of the resident’s ongoing pain or that additional or alternative analgesia was sought, nor was there a physician assessment of the pain in the facility record. The resident continued to report discomfort during repositioning, and upon transfer to the ED was found to have significant ankle pain requiring IV morphine, IV fentanyl, and hospitalization for IV pain control, demonstrating a failure to provide pain management consistent with professional standards.
A resident with an abdominal fistula and diagnoses including respiratory failure and hypertension had detailed physician orders for fistula care using cleansing, zinc oxide with A&D ointment, and panty liner or exu-dry under a brief, with aides allowed to perform the care once trained. The care plan did not include any focus or interventions for the fistula, and clinical notes repeatedly documented use of a colostomy bag and appliance over several days despite no current order for this treatment. The DON and wound nurse reported that staff were trying different methods, including colostomy appliances, and that nurse aides had no appropriate place in the record to document when ordered fistula care was provided, leading to undocumented care and treatment changes made without physician involvement.
A resident with respiratory failure, HTN, and an abdominal fistula requiring specific fistula care orders relied on nurse aides who were permitted to perform this care once shown the procedure. The DON and a wound nurse reported that verbal and hands-on education was provided because aides were unfamiliar and some were fearful or uncomfortable performing the care, and the DON acknowledged that aides sometimes perform tasks outside their usual scope. However, the facility had no documentation of the training, no signed records from the aides, and could not produce a list of which aides had been trained, resulting in a deficiency for failing to ensure and document nurse aide competency in accordance with 483.35(d).
A resident's assessment inaccurately reflected their status regarding insulin use and antipsychotic medication management. The MDS assessments showed insulin injections and changes in orders that were not present, and incorrectly recorded the status of a gradual dose reduction for Seroquel. The DON confirmed these inaccuracies.
The facility failed to update care plans for three residents, omitting necessary medical equipment such as heel protectors, foam boots, and a Carrot splint, despite physician orders. The DON acknowledged these omissions, which were not in line with facility policy.
A resident with hypertension and peripheral vascular disease did not receive necessary pressure ulcer care as their foam boots, ordered for prevention, were repeatedly found off and not documented in the care plan. The DON noted the boots should have been included in the care plan, and staff reported the resident would kick them off, but no documentation was made.
Failure to Use Wheelchair Footrests During Transport Resulting in Ankle Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned safety interventions for a resident during wheelchair transport, resulting in an ankle fracture. The resident had diagnoses including chronic atrial fibrillation and diabetes, and a care plan identifying an ADL self-care deficit related to impaired cognition, muscle weakness, and decreased mobility. The care plan specified that the resident required assistance of one staff for locomotion in a wheelchair and that staff should ensure the resident’s feet sat comfortably on the footrests. A separate fall-risk care plan intervention directed that when the resident was being pushed in the wheelchair, footrests must be in place, and removed only when the resident was self-propelling. On the day of the incident, the resident returned from a leave of absence and was being pushed down the hallway in a wheelchair by an outside transport company. The resident did not have footrests on the wheelchair when leaving or returning to the facility. While being pushed, the resident dropped her right foot, which went under the wheelchair, and she was heard calling out. Initially, no redness or swelling was noted, but later that day the resident complained of right ankle pain, with swelling and redness observed, and the ankle was wrapped and iced. There was no evidence the physician was notified at that time. Overnight, the resident continued to complain of right ankle pain, with warmth, swelling, and sensitivity noted, and an NP ordered an x-ray. The x-ray showed a right bimalleolar ankle fracture, and the physician was later notified and arranged further evaluation, which led to hospitalization and surgery for the fracture. The DON confirmed that the resident broke her ankle due to not having footrests on her wheelchair during transport.
Failure to Adequately Manage Ankle Fracture Pain and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident who sustained an ankle injury. The resident had diagnoses including chronic atrial fibrillation and diabetes and was documented as alert and able to make her needs known. After returning from a leave of absence, the resident’s right foot went under her wheelchair while being pushed by a transport company, and she was heard calling out. Initial documentation on the same day showed no redness or swelling, but the resident reported pain with a pain level of 5 and received 650 mg of acetaminophen twice that afternoon and evening. Later that evening, a health status note documented that the resident complained of right ankle pain, with swelling and redness observed; the ankle was wrapped with an ace bandage and ice was applied, and pain medication was administered. In the early morning hours, another note described continued complaints of right ankle pain, slight warmth, swelling, and sensitivity, and an x-ray of the right ankle was ordered. The MAR showed additional administration of 650 mg of acetaminophen for a pain level of 4. A subsequent note stated that the resident continued to experience right ankle pain and that pain medications were administered with little effect. Despite these ongoing complaints and limited response to PRN acetaminophen, there was no documentation that the physician was notified of the resident’s persistent pain or that additional or alternative pain medications were requested. An x-ray completed later that morning revealed a right bimalleolar ankle fracture. Subsequent notes documented that the resident remained in bed, voiced discomfort to the right lower extremity during repositioning, and received routine pain medication, again without evidence that the physician was notified regarding her pain. There was no physician note or assessment in the facility record addressing the resident’s pain. Hospital emergency department records showed that upon transfer, the resident reported immediate pain to the right ankle since the wheelchair incident, was noted to have significant ankle pain on musculoskeletal exam, and required IV morphine and IV fentanyl, as well as hospitalization for IV pain medications due to insufficient pain control. The facility’s failure to notify the physician and adjust pain management despite documented ongoing pain and ineffective PRN medication resulted in uncontrolled pain and hospitalization for pain management.
Failure to Follow Physician Orders and Document Abdominal Fistula Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and to involve the physician in treatment changes for a resident with an abdominal fistula, as well as the failure to care plan this condition. The resident had diagnoses including respiratory failure and hypertension and was admitted with an abdominal fistula covered by a colostomy bag. Physician orders in January 2026 directed specific abdominal fistula care, including cleansing the abdomen and fistula site, applying zinc oxide mixed with A&D ointment, and covering the fistula with a panty liner or exu-dry under a brief, with aides permitted to perform the care once trained. These orders were active and signed off on the TAR as completed every shift. Earlier in January, there had also been an order for use of an ostomy device and belt over the fistula, which was later discontinued. Despite these orders, the resident’s care plan did not include any focus area or interventions related to abdominal fistula care. Clinical record review showed multiple Health Status notes over several days documenting that the resident’s abdominal fistula was covered with a colostomy bag or colostomy appliance, and that new colostomy pouches were applied and checked frequently. These notes indicated that a colostomy bag was in use on multiple dates, even though there was no current physician order in place at that time for a colostomy bag, and the active order instead described a different fistula care method using zinc oxide and a panty liner or exu-dry. Interviews with the DON and the wound nurse confirmed that nurse aides had received verbal and hands-on training to perform the ordered abdominal fistula care and were providing the treatment, but there was no clear place in the record for them to document when this care was completed. The DON stated that aides would have documented under a bowel and bladder task, but the specific treatment was not an available option, and aides could not document in the TAR. The wound nurse explained that the resident was admitted with a colostomy bag that did not stay on, leading staff to try different methods and to apply whatever worked best at the time, including colostomy appliances without a current order. Both the DON and the wound nurse acknowledged there was no documentation to show when ostomy bags were applied and no task in the record to indicate completion of fistula care, resulting in a lack of adherence to physician orders and inadequate documentation of the resident’s abdominal fistula treatment.
Failure to Ensure and Document Nurse Aide Competency for Abdominal Fistula Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides demonstrated competency in the skills and techniques necessary to provide ordered abdominal fistula care for a resident. The resident had diagnoses including respiratory failure and hypertension and was admitted with an abdominal fistula covered with a colostomy bag. The physician’s order directed specific abdominal fistula care, including cleansing the abdominal area and fistula site, applying zinc oxide mixed with A&D ointment over the abdomen and around the fistula, placing a pantie liner or exu-dry over the fistula, then applying and securing a brief while ensuring the rough tabs did not touch the skin, and changing the dressing as needed or when soiled. The order also specified that aides were allowed to check and change the fistula care once they had been shown how to apply it, and that this care was to be provided every shift. According to the DON, the wound nurse (Employee 1) provided verbal training to nurse aides on how to perform the abdominal fistula care because this was not a type of care they were used to, and nurse aides were initially fearful of completing the order. The DON stated that nurse aides sometimes perform tasks outside their scope of practice and that some aides had reported feeling uncomfortable performing the abdominal fistula care for this resident; in such cases, the DON indicated a nurse would accompany them and that no one would be forced to perform the care if they were uncomfortable. Employee 1 reported that she provided both verbal education and hands-on training to nurse aides on the abdominal fistula care but had no documentation of this training or of which aides received it. The facility was unable to provide a list of nurse aides who completed the training or any documentation indicating that education and training on the abdominal fistula care had been completed, leading to the determination that the facility failed to ensure nurse aide competency as required by 483.35(d).
Inaccurate Resident Assessment for Insulin and Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the status of a resident, specifically regarding insulin use and antipsychotic medication management. The clinical record review and staff interviews revealed discrepancies in the Minimum Data Set (MDS) assessments for a resident diagnosed with diabetes mellitus, psychosis, and muscle weakness. The resident's Quarterly MDS assessments indicated that the resident received one insulin injection in the past seven days and that an insulin order had changed, despite the absence of any insulin orders during the assessment reference date (ARD) lookback period. Additionally, the MDS assessment inaccurately recorded the status of a gradual dose reduction (GDR) for the resident's antipsychotic medication, Seroquel. The assessment indicated that no GDR had been attempted, while a Psychiatry Note documented that a GDR was completed prior to the assessment period. The Director of Nursing confirmed the inaccuracies in the MDS assessments during a follow-up interview, acknowledging that the assessments were not coded correctly.
Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to ensure that the care plans for three residents were reviewed and revised appropriately. Resident 18, diagnosed with muscle weakness, disorders of phosphorus metabolism, and PTSD, had a physician order for heel protectors to be worn while in bed. However, the care plan did not include this requirement, despite a revision date close to the survey date. The Director of Nursing (DON) acknowledged that the care plan should have included instructions for the heel protectors. Similarly, Resident 69, with diagnoses of hypertension and peripheral vascular disease, had a physician order for foam boots to be worn in bed for prevention. The care plan, last revised over a year prior, did not mention the need for foam boots. The DON confirmed that this omission was not in line with expectations. Additionally, Resident 81, who suffers from rheumatoid arthritis and chronic pain, had a physician order for a Carrot splint to be worn at night. The care plan did not reflect this order, and the DON acknowledged that the splint should have been included in the care plan.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services to promote healing and prevent infection for pressure ulcers. The facility's policy on skin integrity interventions includes measures such as frequent repositioning, use of pressure-reducing devices, proper skin care, adequate nutrition, and management of incontinence. However, observations revealed that the resident, who had diagnoses including hypertension and peripheral vascular disease, was not wearing foam boots as ordered by the physician for pressure ulcer prevention. The foam boots were observed on the floor beside the resident's bed on multiple occasions, and there were no progress notes indicating that the resident refused or requested the removal of the boots. Additionally, the resident's care plan, which focused on the risk for impaired skin integrity, did not include the need for foam boots. The Director of Nursing acknowledged that the foam boots should have been included in the care plan and mentioned that staff reported the resident would kick the boots off. However, there was no documentation in the progress notes about the removal of the boots. This lack of documentation and failure to follow the care plan contributed to the deficiency in providing appropriate pressure ulcer care.
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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 Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hill Center For Rehabilitation And Nursing | 1 mi | ★★★★★ | 11 | 0 |
| Spring Creek Rehabilitation And Nursing Center | 6.3 mi | ★★★★★ | 5 | 1 |
| River's Bend Health & Rehab Center | 6.8 mi | ★★★★★ | 18 | 0 |
| Emerald Nursing And Rehabilitation | 8.5 mi | ★★★★★ | 25 | 1 |
| Masonic Village At Elizabethtown | 8.7 mi | ★★★★★ | 2 | 0 |
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