Courtland Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Courtland Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 28, 2026

  Based 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.The findings included: 1. The facility staff failed to provide adequate supervision to ensure Resident #98 was safe from falling while transferring, which constituted harm.Resident #98 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #98 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included Alzheimer's Disease, essential hypertension, major depressive disorder, and muscle weakness. […]

• Actual harm, isolatedF684Mar 17, 2022

  Based 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 [MEDICATION(S)] 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. […]

• Actual harm, isolatedF686Mar 17, 2022

  Based on observation, staff interviews, and clinical record review, the facility staff failed to provide services to prevent pressure ulcers and promote healing for 2 of 9 Residents with pressure ulcers, the facility staff failed to properly classify, assess, and institute an appropriate treatment/care to Resident #8's pressure ulcer to the left hip to prevent deterioration to unstageable, presenting with 70 percent granulation tissue/30 percent slough (dead tissue) over four days, which constituted harm. […]

• Actual harm, isolatedF694Mar 17, 2022

  Based 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 [MEDICATION(S)] 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. […]

• Actual harm, isolatedF697Mar 17, 2022

  Based 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. The findings included: Resident #83 was originally admitted to the facility on [DATE], was discharged to acute care on 11/26/21, returned to the facility on [DATE], and discharged again on 1/1/22, and succumbed on 1/4/22. […]