Courtland Terrace

Based on observations and staff interviews, the facility failed to ensure thawed, raw chicken available for use was labeled with a use by date in 1 of 4 walk-in refrigerators. This practice had the potential to affect food served to residents. Findings included:An observation of the walk-in refrigerator in the main kitchen was conducted on 2/10/26 at 10:18 AM with the Kitchen Operations Manager. At the front of the walk-in refrigerator on the bottom shelf was an opened 20-pound case with one package of raw chicken and one 20-pound case of raw chicken with a sticker that read use first. There was no use by date to specify when the chicken should not be used. The delivery dates on the cases was 2/3/26.During an interview on 2/10/26 at 10:18 AM, the Kitchen Operations Manager revealed when the raw chicken was delivered on 2/3/26 it was frozen and now it had thawed and was ready for use. He revealed the system in place was to rotate frozen raw chicken using a First In First Out policy and explained when raw chicken was delivered it was frozen and placed in the back of the walk-in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, Responsible Party (RP) interview, and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Hospice Care for 1 of 7 residents reviewed for MDS accuracy (Resident #56). The findings included:Resident #56 was admitted to the facility on [DATE] with diagnoses which included chronic ischemic heart disease and chronic obstructive pulmonary disease (COPD). Review of Resident #56's electronic medical record (EMR) revealed a Hospice admission Agreement was signed by Resident #56's RP on 09/08/2025. Resident #56 transitioned to hospice services on 09/08/2025.Review of Resident #56's electronic medical record (EMR) revealed Resident #56's care plan was revised on 09/08/2025 and included the following area of focus, in part: Resident requires Hospice Care and will be kept comfortable through next review.Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #56 was receiving Hospice care.An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, and psychiatrist interview the facility failed to refer one resident with a new mental health diagnosis for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident for PASRR (Resident #10).The findings included:Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE]. A PASRR level I was completed prior to Resident #10's admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Review of the electronic medical record (EMR) revealed Resident #10 was diagnosed with post-traumatic stress disorder (PTSD) on 09/30/2025. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation.An interview with Resident #10's psychiatrist was conducted on 02/12/2016 at 2:00 PM. The psychiatrist stated when Resident #10 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and resident and staff interviews, the facility failed to secure medications left unattended in a resident's room for 1 of 1 resident reviewed medication storage (Resident #90). Findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation and hypertension.Review of Resident #90's active physician orders included apixaban (anticoagulant) 5 milligrams (mg) twice a day started on 2/3/26, metoprolol (antihypertensive) extended release 25 mg with directions to hold for systolic blood pressure (SBP) less than 100 or diastolic blood pressure (DBP) less than 50 or a heart rate less than 50 started on 2/3/26, and diltiazem hydrochloride (antiarrhythmic) extended release 300 mg with directions to hold for SBP less than 120 or DBP less than 60 started on 2/3/26. There was no active physician's order for dextromethorphan/guaifenesin (analgesic/decongestant) 600 mg.During an observation on 2/11/26 at 8:29 AM, a clear resealable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, Guardian, Podiatrist, and staff interviews, the facility failed to provide personal privacy for Resident #28 when the Podiatrist cut her toenails in the facility's day room visible to other residents. This deficient practice was for 1 of 1 resident reviewed for personal privacy (Resident #28). The findings included: Resident #28 was admitted to the facility on [DATE] with diagnoses that included dementia with mood disturbance and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #28 was severely cognitively impaired and exhibited no behaviors or rejections of care during the assessment period. An observation conducted in the facility's day room on 10/30/24 at 12:00 PM revealed there were 10 residents seated at tables around the room. Resident #28 sat in her wheelchair in the center of the room and the Podiatrist sat on the floor in front of her and cut her toenails. There was no privacy curtain or shield in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview the facility failed to maintain the kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean the undershelf of one of one steamtables. The findings included: Review of the Equipment Cleaning Log week of June 18th there was no mention of the steamtable under splash area to be cleaned. An observation of the steamtable undershelf on 6/27/23 at 10:04 AM revealed the steamtable to have splatters of dark black dried food particles covering the under-splash area of the top shelf directly above the food wells. During the meal temperature observation on 6/28/23 at 8:28 AM revealed the 5 well steamtable was observed on and pans of food were in the steamtable ready to serve. The steamtable was observed to have splatters of dark black dried food particles covering the under-splash area of the top shelf directly above the steaming food wells. In an interview on 6/28/23 at 8:39 AM the Operations Manager stated the steamtable should have been cleaned. In an interview on 6/28/23 at 8:45 AM the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to develop care plans in the areas of suprapubic catheter (Resident #45) and pressure ulcers (Residents #4, #9, and #5) for 4 of 4 residents reviewed for care planning. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH) obstructive uropathy. A physician note dated 11/3/22 indicated an indwelling urinary catheter had been placed this day. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #45 had an indwelling urinary catheter. Review of the Resident #45's Comprehensive Care Plan dated 11/8/22 contained no information or interventions regarding suprapubic catheter care. An interview was conducted with the Minimum Data Nurse on 6/28/23 at 4:32 PM. She revealed Resident #45's catheter should have been care planned. An interview was conducted with the Director of Nursing (DON) 6/28/23 at 4:40 PM. The DON stated Resident #45's care plan chould…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to discard an expired medications for 1 of 1 medication room reviewed for medication storage. The findings included: 1.During an observation of the medication room for medication storage on 6/28/23 at 12:02 PM, 1 multidose vial of opened and accessed Tuberculin Purified Diluted (Aplisol) was in the medication refrigerator. The vial had an opened date of 4/15/23. A review of the manufacturer ' s instruction label on the box indicated the medication should be discarded 30 days from the date medication was opened. During an interview with the Director of Nursing on 6/28/23 at 12:10 PM, she stated it was the night shift nurses responsibility to check the refrigerators and medication carts for expired medication. The DON stated the expired medications should have been discarded or returned to the pharmacy. 2. An observation of the medication storage room conducted on 6/28/23 at 12:02 PM revealed 2 bags of Vancomycin 750 milligrams(mg)/ in 250 milliliters (ml) of normal saline with an expiration date of 6/12/23 was in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 7/9/21. This was for a recited deficiency on the current recertification and complaint survey in the area of development and implementation of comprehensive care plans. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews the facility failed to develop care plans in the areas of suprapubic catheter (Resident #45) and pressure ulcers (Residents #4, #9, and #5) for 4 of 4 residents reviewed for care planning. During the recertification survey on 7/9/21 the facility was cited for failing to develop a comprehensive care plan in the areas of indwelling catheter usage and anticoagulant, diuretic, and opioid medication usage. An interview was complete on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.