Courtney Manor

In the surveyor’s words

From the most serious findings on record at Courtney Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 11, 2026

  This 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… […]

• Actual harm, isolatedF697Oct 29, 2024

  Based 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… […]

• Actual harm, isolatedF689Feb 12, 2021

  This Citation pertains to Intake Number MI 728. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for one resident (Resident #7) of three residents reviewed for falls, resulting in numerous documented self-transfers and four unwitnessed falls in a 45 day period, a pelvic fracture and the likelihood for more falls. Findings include: On 2/10/20, at 11:58 AM, Resident #7 was sitting in their wheelchair in the doorway into their room with their bedside table pushed up in front of them which had their lunch tray on top. CNA K was standing to the right side, leaning over Resident #7 and was assisting with a bite of their meal. […]

• No harm, potential for more than minimal, widespreadF880Aug 27, 2026

  This Citation Pertains to Intake 3133516. Based on interview and record review, the facility failed to implement surveillance as part of the facility's Infection Control (IC) program encompassing process surveillance including lack of tracking of potential infections, including rashes, and lack of investigation and identification of trends for scabies (contagious skin infestation caused by microscopic mites) within the facility, resulting in the potential spread of microorganisms and contagious infestations for all 74 facility residents. Findings include:Review of intake documentation dated as received 8/4/26 revealed a concern the facility has a scabies outbreak involving multiple residents and staff. […]

• No harm, potential for more than minimal, widespreadF725Jan 7, 2026

  Based 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. […]