A list of the most recent deficiencies for Courtland, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-09 | 2023-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-09 | 2023-06-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-09 | 2023-04-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-09 | 2023-04-26 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-03-09 | 2023-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-09 | 2023-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-09 | 2023-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-16 | 2023-04-02 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-16 | 2023-04-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-16 | 2023-04-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-16 | 2023-04-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-16 | 2023-04-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-04-02 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-16 | 2023-04-02 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-02-16 | 2023-04-02 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-16 | 2023-04-02 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-16 | 2023-04-02 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-16 | 2023-04-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-16 | 2023-04-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-04-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-04-02 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide appropriate foot care. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-16 | 2023-04-02 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-02-16 | 2023-04-02 | Y |
| Post nurse staffing information every day. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-16 | 2023-04-02 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-16 | 2023-04-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-16 | 2023-04-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-16 | 2023-04-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-04-02 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-16 | 2023-04-02 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-16 | 2023-04-02 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-02-16 | 2023-04-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-16 | 2023-02-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-25 | 2019-03-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-25 | 2019-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-25 | 2019-03-31 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-02-25 | 2019-03-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-18 | 2019-02-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-12-18 | 2019-02-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-18 | 2019-02-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-12-18 | 2019-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-18 | 2019-02-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-12-18 | 2019-02-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-18 | 2019-02-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-18 | 2019-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-18 | 2019-02-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-18 | 2019-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-18 | 2019-02-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-18 | 2019-02-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-12-18 | 2019-02-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-18 | 2019-02-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-12-18 | 2019-02-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-12-18 | 2019-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-18 | 2019-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-18 | 2019-02-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2017-10-11 | 2017-11-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-18 | 2017-10-02 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-18 | 2017-10-02 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-08-18 | 2017-10-02 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-18 | 2017-10-02 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-18 | 2017-10-02 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-18 | 2017-10-02 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-18 | 2017-10-02 | N |
