Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, severe cognitive impairment (BIMS 0), muscle weakness, and documented total-assist/dependent status for transfers was being moved from a wheelchair to a bed by a single CNA. Despite MDS and therapy documentation indicating the need for full assistance and hands-on support, the CNA attempted the transfer alone. During the transfer, the resident became combative and resisted care, the CNA tripped over the leg rest, and both fell, causing the resident to sustain a facial laceration, a closed nasal bone fracture, and a closed nondisplaced C2 fracture, as confirmed by ED records and nursing notes. The DON and rehab director later acknowledged that the resident required continuous hands-on assistance and/or a second staff member for such transfers.
Two residents were affected when staff failed to provide required notifications of changes in condition and room assignments. One resident with multiple comorbidities and moderate cognitive impairment repeatedly reported feeling ill and awaiting test results for suspected flu and UTI, while documentation later showed negative COVID/flu results and a yeast infection diagnosis that were not promptly communicated to the resident, despite orders for multiple labs and provider involvement. Another resident with severe cognitive impairment and Alzheimer's disease experienced five separate room changes documented in the clinical census, and the DON and Administrator acknowledged that the resident's representative was not notified prior to these moves, contrary to facility expectations.
A wandering resident repeatedly entered other residents’ rooms and moved through the unit without staff redirection. Two residents with intact BIMS scores reported that the behavior disrupted their rooms and personal belongings, with one stating the environment did not feel like a home and another reporting that the wandering resident picked up an audiobook and would not leave when asked.
Failure to Educate Residents on Grievance Process: Residents stated they did not know how to file a grievance or how grievances are resolved, and they reported they had never been educated on the process. The Administrator could not explain how residents were educated, the Recreation Director found no evidence of grievance education in Resident Council minutes over an extended period, and the Social Services Director, who served as the Grievance Officer, stated she had never educated residents on the grievance process and was unaware of any other staff member doing so.
Failure to protect a resident from physical abuse occurred when a wandering resident struck another resident multiple times on her previously fractured arm in the dining room. The injured resident, who had dementia and moderately impaired decision-making ability, reported severe pain, and charting documented the attack and ongoing arm pain. Survey observations showed the wandering resident continued moving through the facility without staff intervention, and the DON/Administrator did not treat the event as abuse because they believed it was not a willful act.
Failure to include discharge preferences in comprehensive care plans for two residents. One resident with dementia, colitis, and HTN had a BIMS score showing moderate impairment and stated she wanted discharge to a facility closer to her friend, but the care plan did not reflect that preference. Another resident with intact cognition and diagnoses of HTN and chronic anemia stated his main goal was to leave the facility and return to the community, but his care plan did not address that goal. The SW described barriers to discharge for both residents, but the person-centered care plans did not include their stated preferences.
An LPN was observed splitting an unscored Fluphenazine HCl tablet to give a resident the ordered dose after the medication strength had been changed but the pharmacy had not sent a new package. The facility’s policy stated that if a tablet is not scored, it should not be split. Staff also found an opened vial of Tuberculin PPD in the refrigerator without a date showing when it was opened, and the LPN said she did not know when it had been opened or for whom it was intended.
A resident with diabetes and HF, who was moderately impaired in decision making and dependent for several ADLs, reported that an over-the-bed table had repeatedly fallen onto her knees and caused pain. Staff observed mild redness and a small bruise on the knees, and the Rehab Director stated she tried to repair the table but it would suddenly drop when used, so it was replaced and the defective table was sent to Maintenance.
Failure to Maintain Resident Dignity During Mealtime: An ADON was observed standing over a resident while feeding him for several minutes during a dining observation. The resident had Alzheimer's disease, severely impaired cognition, and needed setup or clean-up assistance with eating. The ADON later stated she should not have done this and acknowledged it was a dignity issue.
Failure to Thoroughly Investigate Missing Resident Property: A resident with dementia and moderately impaired cognition reported that a gifted watch disappeared from her bedside drawer after she placed it there with her cellphones. The DON searched the room and spoke with the resident's daughter, but only the DON actively attempted to locate the watch, no other staff documentation was available, and the grievance was resolved without the watch being found.
Inaccurate MDS Dental Coding: A resident with GI bleeds, stroke, and HTN was assessed as cognitively moderately impaired on the quarterly MDS, but the dental section was coded incorrectly. The resident stated he had no natural teeth or dentures and had not received dental services since admission, yet the MDS listed obvious or likely cavity or broken natural teeth instead of edentulous status.
Failure to involve a resident in her care plan conference. A resident with dementia, colitis, and HTN had a BIMS score of 11/15, indicating moderately impaired decision-making. She said staff told her they would come get her for the conference, but she was not brought to the meeting. The SW said the team wanted the resident's friend present because the resident changed her mind frequently, and when the friend did not show, staff did not escort the resident to the conference; the SW later acknowledged the team made a mistake by not involving the resident.
Failure to provide ADL care to a dependent resident. A resident with a stage 4 PU, paraplegia, and a right AKA was coded as dependent for bathing, toileting, and personal hygiene, yet he reported wanting more showers and being told staffing was short or that he could not shower because of a leg wound. The resident and family also described a prior shower-related injury concern, while the ADL record showed only a few showers and no documented shower refusals in the chart.
Delayed assessment and treatment of a sacral pressure injury. A resident admitted with quadriplegia and a sacral wound had a baseline care plan noting a stage 2 sacral ulcer and a Braden score showing moderate risk, but the wound was not formally assessed by the WCNP until several days later. The record showed no wound care treatment before the WCNP’s assessment, and the MDS skin documentation and weekly skin assessment were also completed late. Interviews reflected conflicting staging of the wound on admission, with the WCNP describing a DTI and the DON stating the wound should have been assessed sooner.
Missing Dialysis Communication Records: A resident with ESRD receiving hemodialysis M/W/F had no dialysis communication notes available in the communication book or medical record for two reviewed dates. The resident said the book was sent to dialysis to communicate care, and an LPN stated it should contain documentation in the book and medical record.
A resident with diabetes, atrial fibrillation, and renal insufficiency was ill and awaiting the results of ordered in-house COVID-19 and flu testing. The resident said she was not informed of the test status or what could be done for her symptoms, and an LPN initially could not confirm the results. A late-entry note was later added showing both tests were negative, but the results had not been documented in the record before the survey inquiry.
Infection control practices were not followed during wound care for a resident with stage 4 pressure ulcers and bowel incontinence. The ADON/IP placed wound care supplies on the bedside table without sanitizing it, then provided incontinent care after a BM and continued wound care while keeping the same gloves on. The ADON later stated she should have washed her hands after incontinent care and used a barrier on the bedside table but forgot.
The facility failed to maintain records of staff COVID-19 vaccinations and did not provide staff with COVID-19 vaccine education, vaccine offers, or information on how to obtain the vaccine. The IP stated education was given only to residents and/or representatives, there were no staff vaccination records, and the IP herself had not received the vaccine. The facility’s COVID-19 protocol stated staff may be employed without proof of vaccination and that the facility will offer vaccine education and vaccination to residents and staff.
Failure to Provide Adequate Supervision During Dependent Transfer Resulting in Fall With Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and safe transfer assistance for Resident #98, resulting in a fall with injury during a wheelchair-to-bed transfer. Resident #98 had diagnoses including Alzheimer's disease, essential hypertension, major depressive disorder, and muscle weakness, and was assessed on the MDS as severely cognitively impaired with a BIMS score of 0/15. The MDS Section GG dated 8/15/23 coded the resident as dependent for chair/bed-to-chair transfers, meaning the helper did all of the effort or that assistance of two or more helpers was required. An occupational therapy treatment note dated 8/25/23 documented that the resident required total assist for stand-pivot transfers to a wheelchair. Despite these documented needs, a single CNA attempted to transfer the resident from a wheelchair to the bed. During the transfer, the CNA and the resident lost their balance and both fell to the floor. Post-fall documentation and the CNA’s statement indicated that the resident became combative, resisted care, pushed against the CNA, and the CNA then tripped over the leg rest, leading to the resident falling face forward to the ground. Nursing notes documented that the resident was found on her left side on the floor with blood present and a laceration to the middle of the forehead, was assisted back to bed with a two-person assist, and was sent to the emergency department. Hospital records and subsequent nursing documentation confirmed diagnoses of a facial laceration, a closed fracture of the nasal bone, and a closed nondisplaced fracture of the second cervical vertebra. The DON and Director of Rehabilitation both stated that, given the resident’s dependent/total assist status for transfers, the CNA should have maintained hands-on assistance at all times and/or had assistance from another staff member during the transfer.
Failure to Notify Residents and Representatives of Test Results and Room Changes
Penalty
Summary
Facility staff failed to promptly notify a cognitively impaired resident of diagnostic test results related to ongoing symptoms. The resident, who had diabetes, atrial fibrillation, and renal insufficiency, reported on multiple occasions that she felt unwell, with nausea, lack of appetite, and suspected flu and UTI, and stated she was awaiting test results. Orders dated 1/19/26 included in-house COVID and flu tests, CBC, BMP, urinalysis, and urine culture and sensitivity. On 1/20/26, 1/22/26, and 1/23/26, the resident continued to report feeling ill and not having been informed of her test results or what could be done for her symptoms. An LPN later confirmed she had not been informed of any test results and needed to consult the unit manager to determine whether tests were completed and what the results were. Documentation showed a late entry nurses' note entered on 1/23/26 for 1/19/26, stating that the resident had been assessed per provider order for COVID-19 and influenza swabs, that results were negative, and that the provider was notified of the negative results. The NP stated it was the responsibility of direct care nurses, not the NP, to notify the resident or representative of test results. The NP also stated she added an addendum to her 1/19/26 progress note on 1/23/26 to document that the nurse had notified her of the test results on 1/19/26. The resident later reported that, after the 1/23/26 conversation, a nurse informed her that she had a yeast infection, would be started on medication, and that she did not have COVID-19 or the flu, indicating a delay in communicating test findings and diagnosis to the resident. Facility staff also failed to notify a resident representative of multiple room changes for a severely cognitively impaired resident with Alzheimer's disease and prostate cancer. The DON reported that this resident had five room changes and that the resident representative was not notified of any of them. Clinical census documentation confirmed room changes on five separate occasions, with moves between different units and room numbers. During a final interview, the Administrator stated that a resident or resident representative needs to be notified prior to a room change, confirming that required notification did not occur in these instances.
Wandering Resident Entered Other Residents’ Rooms
Penalty
Summary
The facility failed to maintain a homelike environment free of a wandering resident for 2 of 51 residents, identified in the report as Residents #36 and #50. Resident #36 was admitted after an acute care hospital stay and had diagnoses including a chronic left lower extremity blood clot, a stage 4 sacral wound, and an anxiety disorder. The resident’s MDS assessment documented a BIMS score of 15 out of 15, indicating intact cognitive abilities for daily decision making. During observations, Resident #22 was seen being pushed rapidly out of a room, later wandering the corridor, stopping at doorways, entering other residents’ rooms, and moving into rooms that were not hers. Resident #22 was also observed entering a dependent resident’s room while the resident asked her to leave, but she continued to move about the room without regard to the request. On another observation, staff did not redirect the wandering resident, and when residents called for assistance to redirect her, she was gone by the time staff responded to the call light. Resident #36 stated that the environment did not feel like a home because doors could not be locked to keep people out, and that wanderers entered rooms regardless of whether residents were in or out. The resident also stated that personal items had been removed from the room and never recovered, and that he had to arrange his bed and belongings to block access to the side of the bed where he kept personal effects. Resident #50 was admitted after an acute care hospital stay and had diagnoses including Parkinson’s disease, heart failure, and macular degeneration. The resident’s MDS assessment documented a BIMS score of 14 out of 15, indicating intact cognitive abilities for daily decision making. Resident #50 stated that because of poor vision, she could not always see what the wandering resident was doing when the resident entered her room, and that asking the resident to leave did not make her leave. She also reported that the wandering resident picked up a book on tape from the bedside, and that she used a bag of popcorn to keep the resident from leaving with the audiobook. Resident #50 stated that the wandering resident did not appear to understand what was said to her and that she feared the resident would take items kept on the over-the-bed table.
Failure to Educate Residents on Grievance Process
Penalty
Summary
The facility failed to educate residents on how to file a grievance and failed to keep residents appropriately apprised of progress toward resolution for 4 of 51 residents in the survey sample, including Resident #14, Resident #16, Resident #10, and Resident #76. During the resident council task on 1/22/26, residents stated they did not know how to file a grievance or what the process was for resolving one, and they reported they had never been educated on the grievance process. During interviews, the Administrator stated residents are educated on the grievance process but could not explain how that education occurs, then said it is done during admission. The Recreation Director, who conducts the monthly Resident Council Meetings, reviewed meeting minutes from April 2023 through the date of interview and stated residents had not been educated on how to file a grievance during that period. The Social Services Director, identified as the Grievance Officer, stated she had never educated residents on how to file a grievance and did not know of any other staff member who had done so. At the final interview, facility leadership had no further comments.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect one resident from physical abuse when another resident wandered into the dining room and struck her multiple times on her previously fractured right arm. The resident involved had dementia, major depressive disorder, and atrial fibrillation, and her annual MDS indicated moderately impaired cognitive abilities for daily decision making. She reported that the other resident hit her 4 to 5 times from behind with a karate-chop motion, causing severe pain in her arm, and that a man in the kitchen intervened to stop the attack. Clinical documentation reflected the resident’s report of the incident and pain, including a nurse’s note documenting pain rated 8 to 10 and a mental health NP note describing the resident’s discussion of the attack and ongoing right arm pain. The NP later noted x-ray findings showed no new findings and that the prior fracture was not completely healed. During survey observations, the resident who attacked her was seen wandering from corridor to corridor and room to room without staff intervention unless a resident called for assistance. The Administrator stated that no Facility-Reported Incident document was completed because she did not consider it an abuse event, believing it was not a willful act and that the other resident wanted the resident’s attention.
Failure to Include Resident Discharge Preferences in Care Plans
Penalty
Summary
Facility staff failed to include discharge-preference information in the comprehensive person-centered care plans for 2 residents. Resident #67 was admitted after an acute care hospital stay and had diagnoses including dementia, colitis, and high blood pressure. Her quarterly MDS, with a BIMS score of 11 out of 15, indicated moderately impaired cognitive abilities for daily decision making. Although her care plan addressed a length of stay to be determined and included an intervention for her to work with staff to go home alone, the record did not reflect her discharge preference in the comprehensive care plan. Resident #67 told staff she wanted to move to a town closer to her friend so the friend would not have to travel 40 minutes to visit, and she stated she wanted the team to work toward discharge to a facility closer to that friend. The Social Worker stated the resident changed her mind frequently, that the resident’s home had been foreclosed on, and that the friend’s apartment was no longer an option. The Social Worker also stated she was assessing the resident’s finances before making further decisions about where she could possibly reside. Resident #25 was admitted after an acute care hospital stay and had diagnoses including hypertension and chronic anemia. His quarterly MDS, with a BIMS score of 15 out of 15, indicated intact cognitive abilities for daily decision making. The MDS coded that active discharge planning was not underway, that the resident did not want to discuss returning to the community, and that no referral had been made to the Local Contact Agency because it was not wanted. However, the resident stated his greatest goal was to get out of the facility, and the care plan failed to address his preferences and goal of returning to the community. The Social Worker stated the resident had previously been planned for discharge home, could not return to his former group home, had limited income, and had recently asked about discharge to Union Mission.
Unsafe medication preparation and undated multi-dose vial
Penalty
Summary
The facility failed to ensure that medications were safe for administration when an LPN was observed cutting an unscored Fluphenazine HCl 10 mg oral tablet to obtain an ordered 15 mg dose for a resident with schizophrenia/psychosis. The physician’s order summary directed that Fluphenazine HCl oral tablet 15 mg be given by mouth twice a day, but the medication label still reflected 10 mg and had been changed to 15 mg on 12/25/25. The LPN stated that a new medication package had not been sent since the dosage change and that the pharmacy had not been notified of what was on hand to administer the ordered dose. The facility’s pharmacy policy stated that if a tablet is not scored, it should not be split. The facility also failed to ensure that an opened multi-dose vial of Tuberculin purified protein derivative was dated when opened. During the medication storage observation, the vial was found in the refrigerator without a date on either the vial or the box, and the LPN stated she did not know when it had been opened or for whom it was opened. The LPN stated that if the date were present, the vial could be used for 28 days. The DON later stated that the undated vial had been removed from use and discarded because the opening date was unknown.
Defective Over-the-Bed Table Injured Resident
Penalty
Summary
The facility failed to ensure resident care equipment was maintained in a safe operating condition for one resident. Resident #3 was admitted with diagnoses including diabetes and heart failure, and the admission MDS coded the resident as moderately impaired for daily decision making, independent with eating and personal hygiene, and dependent for several self-care and mobility tasks including dressing, toileting, bathing, and transfers. During an initial tour, the resident stated that the over-the-bed table had fallen onto her knees again and that she needed pain medication to tolerate the discomfort. She reported that the table had been hitting her knees multiple times each day since admission and that staff had tried to work on it, but it continued to drop down without warning. Observation of the resident's knees showed mild redness on both knees and a small purplish bruise on the right knee. The Rehabilitation Director later stated she had overheard the resident complain about the table, attempted to repair it, found that it would suddenly drop when items were placed on it, and replaced it with another table; she also stated the defective table was given to Maintenance for repair.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to maintain dignity during mealtime for Resident #88 by having the Assistant Director of Nursing stand over the resident while feeding him. Resident #88 was admitted to the facility with diagnoses including Alzheimer's Disease with late onset and malignant neoplasm of the prostate. The quarterly MDS assessment with an ARD of 12/30/25 coded the resident with a BIMS score of 03 out of 15, indicating severely impaired cognitive abilities for daily decision making, and section GG coded him as needing setup or clean-up assistance with eating. During a dining observation on 1/22/26 at approximately 12:21 p.m., the ADON was observed standing over Resident #88 while feeding him and continued to do so for 9 minutes. In an interview on 1/23/26, the ADON stated she should not have been standing over the resident while feeding him and acknowledged it was a dignity issue.
Failure to Thoroughly Investigate Missing Resident Property
Penalty
Summary
Facility staff failed to thoroughly investigate a report of missing personal property for Resident #14, who was admitted after an acute care hospital stay and had diagnoses including dementia, major depressive disorder, and atrial fibrillation. The annual MDS assessment coded the resident with a BIMS score of 10 out of 15, indicating moderately impaired cognitive abilities for daily decision making. The resident stated that a [NAME] watch gifted by her daughter was taken from her bedside table after she placed it in a drawer with her cellphones before bed; the next morning the phones were still there, but the watch was missing. She reported the missing watch to a nurse and stated she believed she knew who took it, although that person denied it. The DON stated she searched under the mattress and in other areas of the resident's room but did not find the watch. The DON also spoke with the resident's daughter, who said the resident was known to misplace items and could not later locate them. A grievance report documented the missing watch, described by the daughter as a brown [NAME] watch with fake diamonds valued at about $250, and noted the grievance was resolved without the watch being located. No documentation was available from any other facility staff showing that they had actively attempted to locate the watch.
Inaccurate MDS Dental Coding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident. The quarterly MDS with an assessment reference date of 1/4/26 coded the resident as having completed the Brief Interview for Mental Status and scored 12 out of 15, indicating moderately impaired cognitive abilities for daily decision making. However, during an interview on 1/20/26, the resident stated that the only assistance he sought was an eye examination and dentures, and said he had not received any dental services since admission. He opened his mouth and showed that he had no natural teeth or dentures. A review of the comprehensive MDS assessment dated [DATE] at section L0200 (Dental) showed the resident was coded as having obvious or likely cavity or broken natural teeth. The Social Worker was informed of the resident's desire for a dental consultation for dentures on 1/28/26, and the MDS Coordinator later confirmed that the assessment was not coded accurately and stated it would be modified to reflect the resident's oral status as edentulous. The resident's diagnoses included GI bleeds, stroke, and high blood pressure.
Failure to Involve Resident in Care Plan Conference
Penalty
Summary
The facility failed to allow Resident #67 to participate in her care plan conference. Resident #67 was admitted after an acute care hospital stay and had diagnoses including dementia, colitis, and high blood pressure. Her quarterly MDS assessment dated 1/15/26 coded a BIMS score of 11 out of 15, indicating moderately impaired cognitive abilities for daily decision making. The resident stated in an interview that she did not like the activities offered and wanted to move closer to a friend so she would not have to travel 40 minutes to visit. She also stated that her care plan conference was scheduled for 1/21/26, but the Interdisciplinary Team did not come to get her as promised, causing her to miss the conference. The resident had a letter stating that her next care conference was scheduled for 1/21/26 at 11:15 AM and that staff would come to her room to escort her to the meeting. The Social Worker stated that the resident came to her office before the conference and was told to wait in her room until her friend arrived, because the team wanted the friend present to help set achievable goals since the resident changed her mind frequently. The Social Worker stated the resident's friend had confirmed attendance but did not show, and because of that the team did not go get the resident for the conference. During a later interview, the Social Worker acknowledged that the team made a mistake by not involving the resident in participation.
Failure to Provide ADL Care and Document Shower Refusals
Penalty
Summary
Facility staff failed to provide ADL care to a dependent resident who was unable to complete bathing, toileting, and personal hygiene independently. Resident #10 was admitted with diagnoses including a stage 4 pressure ulcer of the right hip, a stage 4 pressure ulcer at another site, and acquired absence of the right knee above the knee. The resident’s MDS assessment coded him as cognitively intact with a BIMS score of 15 out of 15, and as dependent for showers/bathing, toileting, and personal hygiene, while independent with eating. The care plan identified an ADL self-care performance deficit related to paraplegia, limited ROM/contracture of the left lower extremity, and right AKA, and included an intervention for bed baths only per resident request. During interviews, the resident stated he wanted more showers but was told the facility needed more help because of short staffing. The resident later reported he had showered the night before and said staff had told him he could not take a shower because of the leg wound. His daughter reported concern that he had been burned on his leg during a shower in 2023, while the resident stated he was not burned but had bumped his leg against a wheelchair and caused bleeding. A CNA stated the resident was offered showers on the 11-7 shift on Thursdays and Sundays and often refused, but the ADL documentation showed showers on only three dates reviewed, and the medical record contained no shower refusals. An LPN could not recall whether the resident refused showers or was scalded, and the DON stated the resident refused showers despite no refusals being found in the record.
Delayed assessment and treatment of sacral pressure injury
Penalty
Summary
Facility staff failed to ensure timely assessment and treatment of a sacral pressure injury for a resident admitted with quadriplegia and a sacral wound. The resident’s admission MDS coded an unstageable deep tissue pressure injury on admission, and the baseline care plan identified a stage 2 sacral wound with the resident at moderate risk for pressure sores based on a Braden score of 14. The hospital discharge summary also noted a sacral wound requiring wound care with a foam border dressing. The medical record showed no wound care admission assessment from 6/9/23 through 6/12/23. The first wound care assessment was completed by the WCNP on 6/13/23, who documented the wound as a deep tissue injury measuring 2.0 cm by 5.0 cm by 0.50 cm, present on admission, with fragile peri-wound tissue and scant serosanguineous drainage. Wound treatment orders were initiated on 6/13/23 for daily cleansing with wound cleanser, medical grade honey, and a bordered foam dressing. The TAR/MAR showed no wound care treatment before 6/13/23. The record also showed that the weekly skin assessment order beginning on 6/9/23 was not initialed until 6/16/23, and the wound documentation in the MDS was not completed until 6/16/23. During interviews, the WCNP stated she assessed the wound as a DTI and said a stage 3 or 4 pressure ulcer was present on admission. An LPN stated she completed the admission assessment and identified a stage 2 pressure ulcer, and said the wound care nurse would come the next day once notified of a wound. The DON stated nursing staff are not allowed to stage wounds and that the wound should have been assessed sooner.
Missing Dialysis Communication Records
Penalty
Summary
The facility failed to maintain ongoing records of communication between the facility and the dialysis center for Resident #11, who had end stage renal disease and required hemodialysis on Monday, Wednesday, and Friday. The resident was originally admitted on 5/23/24 and later readmitted, and the quarterly MDS assessment coded the resident as cognitively intact for daily decision making with a BIMS score of 13 out of 15. The person-centered care plan dated 7/28/25 directed that the resident receive hemodialysis M/W/F and included interventions to check the dialysis port dressing every shift and monitor vascular access every shift. A review of the resident’s dialysis communication book and medical record showed no dialysis communication notes from the dialysis center were available for review on 10/27/25 and 10/29/25. During interview, the resident stated that the dialysis communication book was given to her to take to dialysis to communicate her care. An LPN stated that the communication book goes with the resident to dialysis and should contain communication documentation in the book and in the medical record. At the final interview, the Administrator, DON, and Regional Clinical Director were given an opportunity to provide additional information, but none was provided.
Failure to Document In-House COVID and Flu Test Results
Penalty
Summary
The facility failed to document the results of in-house COVID-19 and influenza testing for one resident. Resident #37 was admitted after an acute care hospital stay and had diagnoses including diabetes, atrial fibrillation, and renal insufficiency. The quarterly MDS coded the resident as moderately impaired in daily decision making, with assistance needs for multiple self-care and mobility tasks. During interviews, the resident stated she was not feeling well, had been awaiting test results after staff suspected flu and a UTI, and later reported ongoing illness, poor appetite, nausea, and that she had not been informed of the status of her test or what could be done for her symptoms. The resident’s physician order summary showed an order for a one-time in-house COVID-19 and influenza test. When interviewed, an LPN stated she had not been informed of the test results and needed to check with the UCM to determine whether the tests had been completed and what the results were. A late-entry nursing note was later added stating the resident had been swabbed for COVID-19 and influenza due to cold-like symptoms and that both results were negative, with the provider notified. The NP stated she had added an addendum to her progress note to reflect that nursing notified her of the negative results, but she was unaware of the direct care nurse’s documentation. The DON stated that the licensed nurse who performed the in-house test was responsible for documenting the results in the resident’s record.
Infection Control Lapses During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was not followed during wound care for Resident #10. The resident was originally admitted on 9/19/2015 and re-admitted from an acute care facility on 7/11/25. The resident’s diagnoses included a stage 4 pressure ulcer of the right hip, a stage 4 pressure ulcer at another site, and acquired absence of the right knee above the knee. The quarterly MDS with ARD 12/22/25 coded the resident as completing the BIMS with a score of 15 out of 15, indicating intact cognitive abilities for daily decision making. The care plan dated revised 1/05/26 identified actual impairment with potential for further skin impairment related to decreased mobility/paraplegia and bowel incontinence, and noted the resident was noncompliant with turning and repositioning and had actual wounds including a stage 4 right ischium wound, stage 4 sacrum wound, and vascular wound to the left lower leg. During wound care observation on 1/22/26, the ADON/Infection Preventionist donned PPE, washed hands, donned gloves, gathered supplies, and placed supplies on the bedside table without sanitizing the table. After removing the old dressing, the ADON doffed gloves and the resident had an incontinent bowel movement. The ADON left the bedside, gathered briefs and incontinent wipes, doffed gloves, donned gloves, provided incontinent care, and then kept the same gloves on while proceeding to provide wound care. The ADON later doffed and redonned gloves again, gathered supplies, placed soiled items in the trash can, doffed the gown and gloves, donned gloves, took soiled items to the soiled utility room, doffed gloves, and washed hands. In interview, the WCN/ADON stated she should have washed her hands after incontinent care and should have placed a barrier on the bedside table before wound care, but said she became nervous and forgot.
Failure to Maintain Staff COVID-19 Vaccination Records
Penalty
Summary
The facility failed to maintain records of staff COVID-19 vaccinations and did not provide staff with education on the benefits and potential risks of the COVID-19 vaccine, nor did it offer staff the vaccine or information on how to obtain it. During an interview with the Infection Preventionist, it was stated that COVID-19 vaccine education was provided only to residents and/or their representatives, that there were no records of staff vaccinations because it was no longer a question asked of current or prospective hires, and that the Infection Preventionist herself had not received the COVID-19 vaccine. The facility protocol titled Guidance and Protocol- COVID-19, revised 7/25/23, stated that staff may be employed without providing evidence of COVID-19 vaccination and that the facility will offer vaccine education and vaccination to residents and staff.
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 8 citations issued within 25 miles in the last 12 months — 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 Courtland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southampton Memorial Hosp | 6.7 mi | ★★★★★ | 0 | 0 |
| Windsor Grove Health And Rehabilitation | 18.7 mi | ★★★★★ | 0 | 0 |
| Waverly Rehabilitation And Healthcare Center | 22.8 mi | ★★★★★ | 5 | 0 |
| Lake Prince Woods, Inc | 24.7 mi | ★★★★★ | 3 | 0 |
| Autumn Care Of Suffolk | 25.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.