Cortland Acres Nursing Home

F-F805 Residents Affected - Some Facility Name: Cortland Acres Health and Rehab

Date of Correction Plan: 3/4/2025

Immediate Actions Taken to Remove the Immediate Jeopardy

1. Resident Safety and Corrective Actions:

As of 03/04/25, all residents on physician-ordered mechanical altered diets were

immediately assessed by the assigned nurse for adverse effects related to improper

texture-modified meals.

2. On 03/4/25, in conjunction with the resident's physician, Director of Nursing, and

Speech Therapist, resident diet orders were update as appropriated to mechanical

soft diet or chopped diet.

3. Staff Education and Re-Training:

Dietary Staff: Immediately or upon arrival to their next worked shift received in-

service training conducted on 03/4/25 by the Dietary Manager and/or designee on:

Proper preparation and delivery of chopped diet, puree diet and

mechanical soft diets

Nursing Staff and CNAs: Re-educated on proper meal modifications and

verifying consistency of food before serving. In-service was provided by the

DON/designee either immediately or upon arrival for their next shift.

4.Monitoring and Quality Assurance Measures:

Daily Meal Audits:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Beginning 03/4/25, the Dietary Manager and Nursing Supervisor conduct meal service audits at every meal to ensure proper diet consistency compliance. Level of Harm - Immediate jeopardy to resident health or Any discrepancies in meal preparation are immediately corrected, documented, and reviewed in daily safety safety huddles.Weekly audits of meal service by the Dietary Manager and Director of Nursing (DON) for four weeks, then ongoing monthly audits. QAPI Committee will review compliance data and discuss any identified Residents Affected - Some trends or issues. Administrator and Medical Director notified of all corrective actions and ongoing monitoring efforts.

On 03/05/25, the surveyor consulted with the facility's corporate team concerning diet cross walks with differing diets per crosswalk from previously ordered diets. Some diets were upgraded and some diets were downgraded. Diets were changed with nursing input, speech therapy input and physician input. Diets were physician ordered. On 03/05/25 at 3:15 PM, Corporate Registered Nurse #172 gave this surveyor a revised diet list with upgraded diets changed and reported the Speech-Language Pathologist will evaluate residents for the safest and most appropriate diet level.

On 03/05/25 at 6:25 PM, the Abatement was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51554

Residents Affected - Some Based upon record review, observation, testing, resident interviews and staff interviews, the facility failed to store, and serve food in accordance with professional standards for food service safety. This has the potential to affect all residents currently residing in the facility. Facility census 91.

Findings included:

a) Expired product:

On [DATE REDACTED] at 10:50 AM during an Initial walk through of dry storage area with Dietary Manager #44, a box of Quaker grits, with expiration date of [DATE REDACTED], was found. When surveyor pointed it out, Dietary Manager said thank you, and she threw the box into the trash.

B) Improper Food Holding temperatures

On [DATE REDACTED] at 5:10 PM, surveyor began observing serving of food in [NAME] Hall dining room.

Surveyor observed Diet Aide #21 while she performed temperature testing of food on the steam table.

Results were:

Burger patties 160 degrees (Appearance was dry and hard)

Baked beans 140 degrees

Coleslaw 38 degrees

Mashed potatoes 161 degrees

Baked beans puree 150 degrees

Gravy 150 degrees

Sliced carrots 170 degrees

Ground beef pieces 160 degrees

Meat puree 120 degrees

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 When asked if these were within range, Diet Aide #21 said no. I will need to call (first name, Dietary Manager #44). She went to the phone and called her. She removed the container from the steam table. DM #44 Level of Harm - Minimal harm or arrived approximately 10 minutes later, and wrapped the puree with plastic wrap and took it back to the potential for actual harm kitchen.

Residents Affected - Some At 6:40 PM, the meat puree is returned to the B dining hall steam table. Temperature was taken as 180 degrees by Diet Aide #21.

On [DATE REDACTED], surveyor observed lunch service in [NAME] dining hall around mid-day.

Temperatures were taken of the food on steam table by [NAME] #3 while surveyor observed.

All temperatures except pureed vegetables were within range. Puree vegetables were at 120. These were sent back to the kitchen and new packages were brought out. These registered a temperature of 160.

c) Hygiene

On [DATE REDACTED] around mid-day, surveyor observation of the lunch service in [NAME] dining hall. NA#6 was assisting the cook on the serving line. First tray was prepared and checked by NHA. Male NA #6 has longish hair which appeared as oily and unclean (about inch below the ear level). He did not don a hair net before stepping into the serving line. When surveyor pointed out the need for a hair net, he did not know where

these were kept. [NAME] #3 reached up and got him one from the shelf above the sink. NHA reminded NA #6 to change his gloves before going back to serving.

d) Facility Policy:

According to the facility's Policy and Procedure Manual for The Dining Experience: Staff Responsibilities,

The dining experience will enhance each individual's quality of life through person-entered dining: providing nourishing, palatable and attractive meals that meet the individuals daily nutritional needs and food and beverage preferences. Food will be served at the proper temperature, texture and/or consistency to meet each individual's needs and desires.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 39043

Residents Affected - Few Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. This was true for one (1) of 31 residents in the long-term care survey sample. Resident identifier: #32. Facility census: 91.

Findings included:

a) Resident #32

Review of Resident #32's physician's orders showed an order for gabapentin (Neurontin) 600 milligrams (mg), give one (1) tablet orally, three (3) times a day for seizures. Resident #32's diagnoses list did not contain a diagnosis of seizures.

On 03/11/25 at 9:28 AM, Assistant Director of Nursing (ADON) #165 stated Resident #32's gabapentin order was incorrect. She confirmed Resident #32 did not have a diagnosis of seizures. ADON #165 stated Resident #32 had started receiving gabapentin in 2020 for diabetic neuropathy. She stated she did not know why the order now showed the medication was given for seizures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 45171 potential for actual harm Based on observation, record review and staff interview the facility failed to implement an ongoing infection Residents Affected - Some prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to

the extent possible. The practices described below had the potential to affect more than an isolated number of residents. Resident identifiers: #74. Facility census: #91

Findings include:

a) On 03/04/25 at 8:48 AM medication administration observation with Register Nurse (RN) #43 revealed the nurse broke Resident #73's Atorvastatin 40 milligram pill in half with no gloves in place. She then placed the broken pill in the medication cup and proceeded to administer it to the Resident.

On 03/04/25 at 8:50 AM it was confirmed with the RN that she was required to use gloves when touching residents medications. It was also confirmed with the Administrator on 03/04/25 at 9:00 AM.

b) Resident #74

On 03/10/25 at 1:24 PM observation of a pressure ulcer dressing change (wound vacuum) was performed. Licensed Practical Nurse (LPN) #117, LPN #28 and Nurse Aide (CNA) #20 were performing or assisting in

this procedure. None of the three (3) staff members were wearing isolation gowns.

Resident #74 was on Enhanced Barrier Precautions (EBP) which required everyone must clean their hands

before entering and when leaving the room. EBP also required providers wear gloves and a gown for the following resident care activities:

Dressing

Bathing/showering

Transferring

Changing Linens

Providing Hygiene

Changing Briefs or assisting with toileting

Devise care or use: central line, urinary catheter, feeding tube, tracheostomy

Wound care: any skin opening requiring a dressing

Resident #74 had an active order that stated EBP related to wounds/peripherally inserted central catheter (PICC)/Percutaneous endoscopic gastrostomy (PEG) feeding tube. (A PICC line is when the IV catheter's tip is positioned in a large vein near the heart, allowing for easier and more reliable access to the bloodstream).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident #74 was care planned for skin impairment related to a pressure ulcer to the coccyx. The care plan interventions included: enhanced barrier precautions.The appropriate signage from the Centers for Disease Level of Harm - Minimal harm or Control and Prevention (CDC) was posted above the residents bed. The appropriate PPE was available potential for actual harm outside the residents door.

Residents Affected - Some The facility Enhanced Barrier Precautions (EBP) policy states:

Specific Procedures/Guidance

4. High-contact Resident Care Activities Requiring EBP:

Dressing

Bathing/showering

Transferring

Changing Linens

Providing Hygiene

Changing Briefs or assisting with toileting

Devise care or use: central line, urinary catheter, feeding tube, tracheostomy

Wound care: any skin opening requiring a dressing

On 03/10/25 at 02:01 PM it was confirmed with the three (3) staff members they should have had the required PPE in placed. Their response was Oh yea. It was confirmed with the Director of Nursing on 03/10/25 at 02:03 PM.

51553

c) On 03/03/25 at 12:07 PM during the Dining Observation at lunch, hand hygiene was not completed by staff for the residents in the main dining room. The Interim Nursing Home Administrator (NHA) confirmed hand hygiene should be completed prior to meals. The NHA stated, hand hygiene was, usually before the meal. The NHA reported hand wipes used to be on the resident's trays, but they were implementing a new system of delivering the plate only from the serving/holding station located in the dining room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 515063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515063 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cortland Acres Nursing Home 39 Cortland Acres Lane Thomas, WV 26292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 51554

Residents Affected - Some Based upon record review and staff interview, the facility failed to complete a minimum of 12 (twelve) hours training during 2024 for nurse aides, including training in caring for residents with dementia and Alzheimer's.

This was true for four (4) of five (5) Nurse Aide (NA) personnel files reviewed during this recertification survey. Facility census: 91

Findings included:

a) NA #5, #13 and #15

Record review revealed that NA #5, #13, and #15 did not have a minimum of 12 hours of training, and there was no training on dementia or Alzheimer's.

NA # 110 was a new hire in 2025.

NA #57 - no dementia or Alzheimer's training

On 03/12/25 around mid-morning, during an interview with HR Manager #170, surveyor reviewed the lack of reaching the 12 hours of annual training required for Nurses' Aides during 2024. The files contained several posttests where education on various subjects appeared to have taken place. However, no one had scored

the post test to determine the knowledge level of the student. There was also no indication of the amount of time spent educating on the subject prior to administering the posttest. HR Manager #170 stated their nursing educator had resigned several months ago.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 515063