Courtland Terrace

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Feb 13, 2026

  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. […]

• No harm, potential for more than minimal, patternF812Jun 28, 2023

  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 [NAME]. 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. […]

• No harm, potential for more than minimal, patternF655Jul 9, 2021

  Based on record review, family and staff interviews, the facility failed to complete baseline care plans in conjunction with the Interdisciplinary Team (IDT), resident and/or responsible party and failed to provide the resident or their responsible party with a written summary of the baseline care plan for 6 of 11 sampled residents reviewed (Resident #49, #3, #4, #226, #232, and #240). Findings included: 1. Resident #49 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] coded Resident #49 with severe cognitive impairment for daily decision making. […]

• No harm, potential for more than minimal, isolatedF641Feb 13, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF644Feb 13, 2026

  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. […]