Courtney Manor

Inspectors wroteThis Citation Pertains to Intake Number 2724891. Based on observation, interview and record review, the facility failed to ensure that interventions were implemented to ensure a safe environment for one resident (Resident #2) of three residents reviewed for falls, resulting in Resident #2 being transferred without an electronic lift which was required by the plan of care, resulting in Resident #2 sustaining several lacerations and a transfer to the hospital. Findings Include: Resident #2:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Heart failure, history of falls, chronic kidney disease, history of a stroke, hypertension, hypothyroidism, atrial fibrillation, left leg pain, arthritis and asthma. [...]

Inspectors wroteThis Citation pertains to Intake Number 2739781. Based on interview and record review, the facility failed to ensure that grievances or concerns were addressed per the facility policy for concerns/grievances for one resident (Resident #6), who had concerns voiced during meetings with the State Ombudsman, of three residents reviewed for complaints.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that there was adequate staff available to meets the needs of the residents, resulting in resident verbalizations of waiting long periods of time to answer call lights and receive assistance with activities of daily living (ADL), including toileting and incontinence care, for a Confidential Group of Residents from a census of 78 residents Findings Include: FACILITY Sufficient and Competent Nurse Staffing: During a review of the facility Offsite survey preparation dated 1/1/2026, the document indicated the facility had Low weekend staffing for the 4th Fiscal Year quarter in 2025; this was July 2025- September 2025. A further review of the CMS (Centers for Medicare and Medicaid Services) PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 (July1 - September 30) identified Excessively Low Weekend Staffing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food-borne illnesses to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' needs were met timely and failed to ensure that call lights were not discontinued without residents' needs being met for three residents (R2, R7, R70) of four residents sampled and a confidential group of residents, resulting in feelings of unimportance and incontinence.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure clinical staff posting was accurately completed for several days in December 2025 and January 2026, resulting in the inability for residents and visitors to know which clinical staff were working on those days. Findings Include: On 1/6/2026 at 11:40 AM, a daily posted nurse staffing sheet (a document listing all nurse staff by discipline (RN, LPN or Nurse aide working in the building on each shift- posted per federal guidelines), titled Report of Nursing Staff Directly Responsible for Patient Care, for 1/6/2026 with a Census of 78 residents was observed posted on the wall in the hallway near the front entryway desk. There were no hours for an RN/Registered Nurse working that day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided to one resident (Resident #6), of one resident reviewed for Activities of Daily Living (ADL) care. Findings Include:Resident #6:On 1/5/26 at 11:21 AM, an observation was made of Resident #6 (R6) lying on her back in bed, dressed in a gown, lights on and R6 was awake. The call light was hanging on a piece of plastic on the wall, in line with the Resident's feet and not in reach for the Resident with the push mechanism hanging below bed frame. The Resident was asked questions, answered them, but did not engage in conversation. The Resident pulled the covers up around her shoulders. An observation was made of long fingernails. The Resident reported she didn't want to answer questions and turned herself facing the wall. The Resident was left alone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident (Resident #25), with a significant weight loss, was weighed as ordered by the practitioner and the weights were documented in the medical record of two residents reviewed for nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor, and provide pain management for two residents (Resident #138, Resident #139) of 6 residents reviewed for pain management, resulting in the residents' verbalizations of unrelieved pain, frustration and helplessness. Findings Include: Resident #138: Pain Management A record review of the Face sheet and electronic medical record (EMR) for Resident #138 indicated the resident was admitted to the facility on [DATE] with diagnoses: pancreatic cancer, right upper quadrant abdominal swelling, mass and lump, anemia, diabetes, anxiety, depression, malignant ascites (fluid build up in abdomen), heart disease, right buttock Stage 2 pressure ulcer, left buttock Stage 3 pressure ulcer and GERD (gastroesophageal reflux disease). The resident was receiving Hospice services and died on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that call lights were answered timely, with dignity, were within reach and needs were met timely, 2) Failed to provide assistance with feeding in a dignified manner, 3) Failed to ensure that food was a palatable temperature, offered substitution of meal items, and ensure the opportunity to eat in the dining room, and 4) Failed to ensure that residents could go outside for a confidential group of residents and Residents (#3, #15, #16, #29, #37, #44 and #64), resulting in complaints of frustration, unhappiness, delayed care with a likelihood of overall decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that residents' rooms, were clean, uncluttered, and in good repair, resulting in an unhomelike physical environment, with electric razors plugged in and resting over the back of toilets, chairs in disrepair and residents' rooms with drywall gouges and holes in the walls. Findings Include: FACILITY Environment On 10/27/2024 at 12:35 PM, Resident room [ROOM NUMBER] was observed to have large gouges and holes in the wall. When a Confidential Resident was asked about the damaged wall, the resident stated, They were going to fix it and didn't. I've been here since the beginning of the year. The gouged and open areas were near the head of the bed behind the chair and on the other side of the room on the opposite wall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that professional standards of care were followed during medication administration of nebulizer treatment for one resident (Resident #82) and supervision of medication administration for one resident (Resident #50), of seven residents reviewed for medication administration, resulting in Resident #82 not observed during the administration of nebulizer medication, a lack of getting the prescribed amount of nebulizer medication, and the likelihood of medication not administered as prescribed/scheduled for Resident #50 and the exacerbation of medical conditions

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure sufficient nursing staff were available for a timely and adequate resident care for eight residents (R29, R38, R41, R61, R64, R80, R138, and Resident in room [ROOM NUMBER]B), of eight residents reviewed for adequate staffing resulting in long call light responses, unmet resident care needs, and late medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than 5% when 23 medication errors were observed for four residents (#35, #75, #78 and #82) from a total of 69 opportunities, of seven residents observed for medication administration, resulting in an error rate of 33.33% with the potential for adverse reactions related to the omission of medications and medications not administered timely with the potential of ineffective medication therapy and the exacerbation of medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that ongoing surveillance for signs and symptoms of infectious illnesses in residents was collected, documented, analyzed and reported and 2) Failed to ensure that Transmission-Based Precautions were identified and Personal Protective Equipment/PPE was worn when indicated, hand hygiene was performed, when necessary, needles were not recapped, personal items were labeled with residents' names in shared bathrooms, and hair nets were readily accessible without risk of cross-contamination in the kitchen, resulting in a lack of compliance with infection prevention and control standards of practice which could result in exposure to infectious organisms and an outbreak of illnesses. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on advanced directives with the proper POA signature of DNR consent and ensure that the care planning matches the desired code status for 2 residents (Resident #47 and Resident #71) of 2 residents reviewed for code status resulting in lack of accurate assessment and documentation of code status and the potential for a resident to receive life-sustaining medical treatment against their wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive revised care plans for four residents (#26, #47, #53 and #68) out of five residents reviewed for care planning, resulting in unassisted unsafe ambulation, unassessed nutritional needs with the likelihood of unmet care needs and code status and the potential for a resident to receive life-sustaining medical treatment against their wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) care for two residents (Resident #23, Resident #74) of 18 residents reviewed for ADL care, resulting in soiled hands, unkempt appearance, and a lack of showering/bathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ambulation supervision and ensure that a safety care plan was followed for two residents (Resident #71 and Resident #38) at risk for falls, and prevent/assess/document an injury from furniture in disrepair for one resident (Resident #68), of 4 residents reviewed for falls and safety, resulting in the potential for serious harm or injury from a fall and a delay in treatment for R#68's forearm cut from a sharp edge of broken furniture.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that urostomy appliance changes were ordered timely, completed per physicians' orders, and there was a completion of a comprehensive bladder elimination care plan and 2) Failed to obtain a physician's order for a urinary indwelling catheter for two residents (Resident #23, Resident #26), resulting in delayed and missed urostomy appliance changes, unmet care needs with the likelihood of further missed care needs, infection and complications from an indwelling urinary catheter.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor and ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident #139) of 5 residents reviewed for food or nutrition, resulting in Resident #139 lacking nutritional assessments to aid in the identification of nutritional needs. Findings Include: Resident #139: Nutrition On 10/27/2024 at 2:38 PM, Resident #139 was heard yelling out and moaning. He was observed sitting in bed with his lunch tray at the bedside. The lid was on it and the resident said he did not feel like eating. He said after a while they would take his meal tray. He said he wished they wouldn't take it. A record review of the Face sheet and medical record indicated Resident #139 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that orders from the dialysis center were communicated to the practitioner for 2 residents (Resident #23 and Resident #139) of two residents reviewed for dialysis care, resulting in the potential for missed medication regimen, treatment and complications of dialysis care. Resident #23: A review of Resident #23's medical record revealed an admission into the facility on 8/3/24 with diagnoses that included chronic kidney disease, muscle weakness, need for assistance with personal care, obesity, and dependence on renal dialysis. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathe self. On 10/27/24 at 1:31 PM, an observation was made of Resident #23 sitting in her recliner chair and was dressed. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that narcotic medication reconciliation was completed, 2) Failed to ensure that residents received medications timely, and 3) Failed to ensure that the medication administration standards of practice were followed for four residents (#34, #75, #78 and #82) of seven residents observed for medication administration, resulting in medications not given as scheduled with the likelihood of ineffective medication therapy, exacerbation of medical conditions, medication/narcotic diversion, and medication administration errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enough healthy snack choices for all residents, resulting in Resident Council-voiced complaints, missing and low snack list items, and feelings of decreased over all well-being and frustration.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure: that sound levels of call lights were appropriate for the resident population in the 200 Hall and 2) Failed to ensure dignity in regard to call lights by not responding timely for two residents (Resident # 66 Resident #76), resulting in residents verbalizing complaints of lack of response, frustration, agitation, and the likelihood for behaviors.

Inspectors wroteResident #41: On [DATE] at 12:40 PM, a review was conducted of Resident #41's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Bacteremia, Cellulitis, Atrial Fibrillation, Heart Disease and Presence of Automatic Cardiac Defibrillator. Further review of Resident #41's record yielded the following results: Hospital Discharge Records: .AICD (automatic cardioverter/defibrillator) present . Facility admission Assessment [DATE]: - Pacemaker: Yes Care Plan: Focus: (Resident #41) is at risk for cardiac complications r/t multiple cardiovascular diseases, hypertension, atrial fibrillation, hyperlipidemia, CAD, hx of STEMI and presence of AICD. Progress Notes: [DATE] at 00:00: Notified by nursing the resident will be transferred to the hospital due to sternal abscess which has copious drainage. [DATE] at 06:34: [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00135049 and MI00135826. Based on observation, interview, and record review the facility failed to ensure that there was adequate staff and/or that staff were utilized appropriately to provide Activities of Daily Living (ADL) and answer call lights timely, resulting in delays in incontinence care, increased call light response times of 30 minutes or more and other unmet care needs. Findings Include: During initial tour on 10/4/202, Resident #79 expressed complaints related to the facility's call light response times. Resident #79 shared sometimes facility staff complete check and changes and other times they do not. She stated she has not been changed since 5 AM and had urinated multiple times since then but no one had been in to check on her. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure: that ice machines in the 200, 400 and 900 halls were clean and sanitary and 2) Failed to ensure that the salad bar cabinet did not have standing water underneath and that items were not stored under the cabinet , resulting in the potential for the spread of foodborne illness to all residents receiving meal service from a census of 81 residents. Findings Include: FACILITY Kitchen On 10/04/23 at 10:25 AM, during a tour of the kitchen with the Certified Dietary Manager/CDM H and Kitchen Supervisor M, the salad bar cabinet in the main dining room was observed to have standing water underneath and inside the cabinet. A 5 gallon bucket was under the drain in the upper compartment of the cabinet. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00135826 and MI00138777. Based on observation, interview and record review, the facility failed to ensure that infection control standards of practice were followed for: 1) Collection, analysis and reporting of infection surveillance data, 2) Multiple residents having a rash of unknown origin on the 200 Hall, and 3) Hand hygiene practices, resulting in the potential for resident, staff and visitor exposure to infectious illness. Findings Include: FACILITY Infection Control: Resident #56: On [DATE] at 1:29 PM, during a tour of the facility, Resident #56 was observed sitting in a wheelchair in the 200 hallway and stated, They are battling people that are itching here. I'll go out in the hall and you'll see people just scratching. They don't know what it is. I think some have it bad. Across the hall (Resident #65) has it terrible; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update a care plan for catheterization for one resident (Resident #80), resulting in the catheter interventions not addressing the resident's self-catheterization and accompanying education, which was to be provided per physician's order.

Inspectors wroteBased on observation, interview and record review, the facility failed to educate and provide proper management of self-catheterization for one resident (Resident #80), resulting in the potential for bladder injury, cross contamination, and resultant urinary tract infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate completion of a trauma assessment for one trauma survivor, Resident #9, resulting in the facility not being aware of Resident #9's trauma history and subsequently not being able to deliver culturally competent trauma-informed care and identify triggers to minimize re-traumatization. Findings Include: Resident #9: On 10/4/2023 at approximately 2:30 PM, Resident #9 was observed resting in bed and was in a pleasant mood. The survey system indicated Resident #9 triggered for PTSD (Post Traumatic Stress Disorder) and she was queried if this was accurate, and she responded it was. The resident was asked if she was comfortable sharing a generalized statement regarding her trauma (type of trauma and if in childhood or adulthood). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have two nurses sign off on a Fentanyl patch removal and administration for one resident (Resident #3), resulting in the likelihood of narcotic diversion and the narcotic diversion going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that 1 of 3 medication carts were free from loose tablets/medications and 2) Failed to perform hand hygiene during medication pass, resulting in the likelihood of cross contamination and ineffective medications.