THOMAS, WV - Federal inspectors found immediate jeopardy conditions at Cortland Acres Nursing Home in March 2025 when residents on physician-ordered mechanical altered diets received improperly prepared meals, creating serious choking and aspiration risks for vulnerable patients with swallowing difficulties.
The March 12, 2025 inspection revealed widespread failures in food safety, infection control, and staff training that put the facility's 91 residents at risk. The most serious violation involved serving incorrectly textured foods to residents who required modified diets for safe swallowing, a potentially life-threatening error that triggered immediate corrective action.
Emergency Diet Safety Crisis Creates Life-Threatening Conditions
The most critical violation at Cortland Acres involved improperly prepared texture-modified diets for residents with swallowing difficulties. Inspectors discovered that residents prescribed mechanical soft, chopped, or pureed diets were receiving foods with inappropriate textures, creating significant choking and aspiration hazards.
During meal service observations, inspectors documented multiple instances where meat puree registered dangerously low temperatures of only 120 degrees, well below the required 140-degree minimum for safe food holding. When dietary staff member Diet Aide #21 discovered the temperature violation, she stated "no, I will need to call" the dietary manager and removed the unsafe food from service.
The immediate jeopardy finding required the facility to take emergency action. On March 4, 2025, all residents on physician-ordered mechanical altered diets underwent immediate nursing assessments for adverse effects from receiving improperly textured meals. Working with physicians, the Director of Nursing, and Speech Therapist, the facility updated diet orders to ensure appropriate texture modifications.
Texture-modified diets serve a critical medical purpose for residents with dysphagia (swallowing difficulties), often caused by stroke, dementia, or neurological conditions. When residents with compromised swallowing receive regular-textured foods, they face serious risks including choking, aspiration pneumonia, and potentially fatal respiratory complications. The esophagus and airway structures work precisely together during swallowing, and any disruption to this process can allow food particles to enter the lungs.
Mechanical soft diets require foods to be ground or minced to reduce particle size, while pureed diets must achieve a smooth, pudding-like consistency. These modifications reduce the muscular effort needed for swallowing and minimize the risk of food particles becoming lodged in the airway. The facility's failure to properly prepare these specialized diets directly compromised resident safety.
Food Safety Failures Expose Residents to Contamination Risks
Beyond the diet texture crisis, inspectors found multiple food safety violations that created additional health hazards. During kitchen inspections, expired Quaker grits were discovered in dry storage, which the dietary manager immediately discarded when notified by surveyors.
Temperature monitoring revealed systematic failures in maintaining safe food temperatures. Hot foods must be kept at 140 degrees Fahrenheit or above to prevent bacterial growth that can cause foodborne illness. However, inspectors documented pureed vegetables at only 120 degrees during lunch service, requiring removal and replacement with properly heated items.
The temperature violations extended to both hot and cold foods. While cold items like coleslaw maintained appropriate temperatures at 38 degrees, multiple hot food items fell below safety thresholds. When unsafe temperatures were identified, dietary staff demonstrated awareness of the problem but revealed gaps in consistent monitoring procedures.
Proper food temperature control prevents the growth of harmful bacteria such as Clostridium perfringens and Staphylococcus aureus, which multiply rapidly in the "danger zone" between 40-140 degrees Fahrenheit. For elderly nursing home residents with compromised immune systems, foodborne illnesses can cause severe complications including dehydration, hospitalization, and life-threatening infections.
Infection Control Breakdowns Compromise Medical Safety
Inspectors identified serious gaps in infection prevention protocols that increased disease transmission risks. During wound care for a resident on Enhanced Barrier Precautions (EBP), three staff members - two Licensed Practical Nurses and one Nurse Aide - failed to wear required isolation gowns during a pressure ulcer dressing change involving a wound vacuum system.
The resident had active orders for Enhanced Barrier Precautions related to wounds, a PICC line, and PEG feeding tube. These precautions specifically require gowns and gloves for wound care activities to prevent cross-contamination between residents and protect healthcare workers from exposure to infectious agents.
When questioned about the missing protective equipment, staff responded "Oh yea" acknowledging they should have followed proper protocols. The Director of Nursing confirmed the violation during the inspection.
Additionally, during medication administration, a Registered Nurse broke a resident's Atorvastatin pill in half with bare hands, violating basic infection control principles. Hand contact with medications can introduce contaminants and potentially transfer infectious agents between residents.
Enhanced Barrier Precautions represent a critical infection control strategy, particularly important for residents with open wounds, central venous access devices, and feeding tubes. These medical devices create direct pathways for bacteria to enter the bloodstream, making strict adherence to protective protocols essential for preventing healthcare-associated infections.
Staff Training Deficiencies Leave Caregivers Unprepared
The facility failed to meet federal requirements for ongoing staff education, with four of five reviewed nurse aides lacking the minimum 12 hours of annual training required during 2024. More concerning, staff records showed no training on dementia and Alzheimer's care, despite serving residents with cognitive impairments.
Training documentation revealed incomplete educational processes. While post-tests were administered on various subjects, no scoring had been completed to assess knowledge comprehension, and time spent on educational content was not documented. The HR Manager acknowledged their nursing educator had resigned several months prior, leaving training programs inadequately managed.
Federal regulations require comprehensive ongoing education to ensure staff maintain competency in caring for elderly residents with complex medical conditions. Dementia and Alzheimer's training is particularly crucial, as these conditions affect communication, behavior, and safety needs requiring specialized care approaches.
Medical Record Errors Create Medication Safety Concerns
Inspectors found documentation errors that compromised medication safety oversight. One resident's physician orders listed gabapentin 600mg three times daily "for seizures," but the resident's diagnosis list contained no seizure disorder. The Assistant Director of Nursing confirmed the resident did not have a seizure diagnosis and had been receiving gabapentin since 2020 for diabetic neuropathy.
Accurate medical records ensure appropriate medication monitoring and prevent adverse drug interactions. When medication indications are incorrectly documented, it can lead to inappropriate prescribing, monitoring failures, and potential medication errors that endanger resident safety.
Additional Issues Identified
The inspection revealed several other violations requiring correction:
- Hygiene failures during food service, including a nursing aide with unkempt hair serving food without proper head covering until reminded by inspectors - Hand hygiene omissions before resident meals, with the administrator acknowledging hand sanitization "usually" occurred before eating - Documentation gaps in medical records affecting medication safety oversight - Policy compliance failures across multiple departments requiring systematic retraining
The facility implemented immediate corrective measures including daily meal audits, comprehensive staff retraining, and enhanced monitoring protocols. Corporate nursing staff conducted revised diet assessments, and speech-language pathologists evaluated residents for appropriate diet modifications. The immediate jeopardy finding was resolved by March 5, 2025, following implementation of emergency safety measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cortland Acres Nursing Home from 2025-03-12 including all violations, facility responses, and corrective action plans.
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