Courtland Rehabilitation and Healthcare Center

Inspectors wroteBased on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 51 residents (Resident #98), in the survey sample which constituted harm.

Inspectors wroteBased on resident and staff interviews and a review of clinical records, the facility staff failed to notify the resident and/or the resident representative of changes for 2 of the 51 residents in the survey sample (Residents #37 and #88).

Inspectors wroteBased on observations and interviews with residents and staff, the facility staff failed to ensure a homelike environment for 2 of the 51 residents in the survey sample (Residents #36 and #50).

Inspectors wroteBased on information from the resident council task, resident interviews, staff interviews, and review of facility documents, the facility staff failed to educate the residents on how to file a grievance and resolve grievances as well as keeping the residents appropriately apprised of progress toward resolution for 4 of 51 residents (Resident #14, Resident #16, Resident #10, and Resident #76) in the survey sample.

Inspectors wroteBased on interviews with residents and staff and a review of the clinical record, the facility staff failed to protect 1 of the 51 residents in the survey sample (Resident #14) right to be free from physical abuse. Resident #14 was initially admitted to the facility on [DATE] following an acute-care hospital stay. The residents' current diagnoses include dementia, major depressive disorder, and atrial fibrillation. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/24/25, coded that the resident had completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated that Resident #14's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: [...]

Inspectors wroteBased on resident and staff interviews and a review of clinical records, the facility staff failed to include the discharge-preference information for 2 of 51 residents (Resident #67 and #25) in the survey sample.

Inspectors wroteBased on observations during the Medication Storage and Labeling and Medication Administration tasks, staff interviews, and a review of clinical records, the facility failed to ensure that medications were safe for administration.

Inspectors wroteBased on observations, resident and staff interviews, and a review of clinical records, the facility staff failed to ensure resident care equipment was maintained in a safe operating condition for 1 of 51 residents (Resident #3) in the survey sample.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to maintain dignity during mealtime for 1 of 51 residents (Resident #88), in the survey sample.

Inspectors wroteBased on resident and staff interviews and a review of facility documents, the facility staff failed to thoroughly investigate a report of missing personal property for 1 of 51 residents (Resident #14) in the survey sample.

Inspectors wroteBased on observations, resident and staff interviews, and a review of the clinical records, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 51 residents (Resident #52) in the survey sample.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed allow the residents' involvement in the care plan conference for 1 resident (Resident #67) in the survey sample of 51 residents. The findings Include:The facility staff failed to allow the residents' involvement in the care plan conference on 1/21/26. Resident #67 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' diagnoses included dementia, colitis, and high blood pressure. The quarterly MDS assessment, with an assessment reference date (ARD) of 1/15/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 11 out of a possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were moderately impaired. [...]

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to one dependent Resident (Resident #10) in a survey sample of 51 Residents.

Inspectors wroteBased on family interview, staff interview, clinical record review and review of facility documentation the facility staff failed to ensure the necessary treatment, care and services were initiated for a Stage 2 pressure ulcer for 1 of 51 residents (Resident #96), a closed record resident, in the survey sample.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 1 of 51 residents (Resident #11), in the survey sample.

Inspectors wroteBased on resident and staff interviews and a review of clinical records, the facility staff failed to document the results of in-house COVID and influenza tests for 1 of the 51 residents in the survey sample (Resident #37).

Inspectors wroteBased on observations and staff interviews the facility staff failed to follow infection control practices. Therefore, increasing the chances of spreading infections, illnesses and diseases for 1 of 51 residents, Resident #10 in the survey sample.

Inspectors wroteBased on staff interviews and a review of Infection Control documentation, the facility failed to maintain records of staff COVID-19 vaccinations.

Inspectors wroteBased on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and treatment for 5 out of 44 residents (Resident #84, #64, #79, #56, and #71) in the survey sample. For Resident #84, the facility staff failed to follow the Nurse Practitioner (NP) orders to provide parenteral Intravenous (IV) fluids as ordered on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated for a resident who had a decline in oral fluids, decrease appetite and having loose stools. Resident #84 remained in the facility for 28 hours after the order was given on 02/04/22 to start IV fluids. [...]

Inspectors wrote2. a. Resident #26 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident was never been discharged from the facility. According to the comprehensive skin assessment dated [DATE] at 8:12 PM a new wound was found on the resident's Sacrum. Acquired in-house. With 100% slough/eschar. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/26/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated that Resident #26 cognitive abilities for daily decision-making were moderately impaired. In section E (Rejection of Care) did the resident reject evaluation or care, marked O behavior not exhibited. [...]

Inspectors wroteBased on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and services for 2 of out 44 residents (Resident #84 and #71) in the survey sample. For Resident #84, the facility staff failed to provide parenteral intravenous (IV) fluids as ordered by the Nurse Practitioner on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated. Resident #84 remained in the facility for 28 hours after the order was given to start IV fluids before the resident was noted as being in respiratory distress, unable to obtain blood pressure, and using his accessory muscles for breathing. [...]

Inspectors wroteBased on information gleaned during a complaint investigation, family interview, staff interviews, and a clinical record review, the facility staff failed to admit and transcribe orders to obtain crucial pain medications for over forty-five hours to manage the pain for a resident two days post-surgery after a serious and complex lumbar fusion of the spine, resulting in severe pain which limited participation in day to day activities, the ability to sleep at night and physical decline which constituted harm for 1 of 44 residents (Resident #83), in the survey sample.

Inspectors wroteBased on information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on observations during the tray line service, resident interview, staff interviews, and clinical record review, the facility staff failed to serve proper meat portions and mashed potatoes per recipe to provide person-centered determined nutritional needs based on the Registered Dietitian's assessment for 71 of 83 residents in the facility.

Inspectors wrote4. The facility staff failed to notify Resident #87's responsible party timely of an acute change of condition that required the resident to be transferred to the hospital on 2/3/22 via 911. Resident #87 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Kidney Disease, Stage 5. Diabetes Mellitus, Anemia, Obesity, and Atrial Fibrillation. Resident #87 was discharged to the hospital on 2/3/22. The most recent comprehensive Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 1/27/22. The Brief Interview for Mental Status for Resident #87 was coded as a 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Under Section F0400 Interview for Daily Preferences Resident #87 was coded as a 1-Very Important for: [...]

Inspectors wroteBased on employee record review, facility document review and staff interviews the facility staff failed to implement their Abuse/Neglect Prevention Policy for screening of new employees. Criminal Background Checks were not obtained for 12 current employees within 30 days of their hire date, Sworn Statements were not obtained for 16 current employees upon hire, and a Nursing License was not obtained for 2 current employees upon hire.

Inspectors wroteBased on a family interview, staff interviews, and review of facility documents, the facility staff failed to have on duty sufficient nursing staff with the appropriate skills sets to provide nursing services during the 3:00 p.m. - 11:00 p.m., shift on 11/19/21.

Inspectors wroteBased on record review and staff interview the facility staff failed to ensure Agency Staff completed appropriate competencies and skill sets to provide nursing related services to meet resident needs.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation, the facility staff failed to administer a significant medication for 1 out of 44 residents (Resident #47) in the survey sample.

Inspectors wroteBased on staff interview, facility record review, and review of the facility's policy, the facility staff failed to consistently have the Medical Director or Designee present for 1 of 4 quarterly meetings.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to invite 1 of 44 residents (Resident #64) in the survey sample to participate in her Person-Centered care plan meeting.

Inspectors wroteBased on record review, staff and individual interviews the facility staff failed to provide one resident (Resident #37) in the survey sample of 44 residents with a quarterly financial statement.

Inspectors wroteBased on staff interviews, and clinical record review, the facility staff failed to complete and implement the baseline care plan within 48 hours of a resident's admission and failed to provide a written baseline care plan summary to one resident representative for 2 of 44 residents (Resident #83 and #67), in the survey sample.

Inspectors wroteBased on record review, staff and resident interviews, the facility staff failed to revise the care plan for one resident, Resident #37, in the survey sample of 44 residents, to include interventions for this resident sharing alcohol with other residents.

Inspectors wroteBased on observations, medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 44 Residents (Resident #61) was provided an assistive device to prevent accidents, Resident #61. The facility staff failed to ensure Resident #61's wanderguard device was in place to prevent elopement.

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a resident who receives oxygen therapy for COPD and CHF had oxygen flowing for 1 of 44 residents (Resident #56), in the survey sample.

Inspectors wroteBased on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to have an ongoing review of antibiotic stewardship and monitor the effectiveness of the resident's antibiotic therapy.

Inspectors wroteBased on observation, resident and staff interview the facility staff failed to maintain an ongoing pest control program to ensure the facility is free of insects.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide evidence that 4 of 44 residents in the survey sample, were given the opportunity to formulate an advance directive; Residents #24, #81, #73, and #37.

Inspectors wroteBased on resident interviews, family interview, staff interviews, and clinical record review, the facility's staff failed to provide necessary care and services to 1 of 41 residents (Resident #132), in the survey sample to manage diabetes by obtaining blood sugars, and administering blood sugar medications. This failure resulted in more than minimal consequence for the resident, with blood sugar readings ranging 450 - 577 mg/dl, accompanied by chest pain which required an emergency room visit and 24 hour observation for stabilization at an acute care hospital.

Inspectors wroteBased on facility record review and staff interviews the facility staff failed to ensure implementation of an ongoing antibiotic stewardship program.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement abuse policies and thoroughly investigate a skin injury of unknown source on two occasions for one of 44 residents in the survey sample, Resident #44.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to thoroughly investigate a skin injury of unknown source on two occasions for one of 44 residents in the survey sample, Resident #44.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review the facility staff failed to adhere to accepted standards of quality for medication administration for 1 of 44 residents in the survey sample, Resident #66. The facility staff failed to ensure medications were administered as ordered and failed to observe Resident #66 ingest the ordered medications.

Inspectors wroteBased on clinical record review and staff interviews, the facility staff failed to ensure 1 of 44 residents (Resident #39), in the survey sample, did not receive as needed (PRN) Ativan for greater than 14 days without the physician and/or prescribing practitioner evaluating the resident for the appropriateness of continuous PRN use.