Inspection·January 23, 2020

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was having pain and Resident #40 revealed she had brain surgery the day before, her head was hurting and she was waiting for her pain medication to be given soon and did not feel like talking to the surveyor. Resident #40 said the staff was aware she needed her pain medication. Observation and interview were conducted on 01/23/20 at 11:55 A.M. with Resident #40 who was found sitting up on the side of her bed with her head down to her chest and arms to her sides pressing up on the bed frame as to alleviate pressure on her bottom. Resident #40 indicated her pain was a level eight and she had told State Tested Nurse Aide (STNA) #402 about an hour prior that she needed her pain medication. When asked if her pain medication was effective she revealed she did not always get her medication when she needed it but if she did it helped a lot but she had chronic pain. When asked for further detail she said the staff will not wake her for the pain medication if she is sleeping. She said it had happened on a few occasions with the same nurse ( resident named RN#601 ) or if she asked for her pain medication an hour early they would leave her waiting for an hour or more because they were too busy to bring it to her. Resident #40 shared she wanted to be woken up to receive her pain pill or else when she did wake up her pain would be to the point where she could not function. Resident #40 shared she had a degenerative spine and it was really hurting her and she was upset it had been almost an hour since she told STNA#402 to tell the nurse she needed her pain pill. Interview was conducted on 01/23/20 at 12:13 P.M. with LPN#500 and RN#600 who were both at the medication carts at the nurses station. LPN#500 identified herself as the nurse caring for Resident #40. When asked if STNA#402 had told her about the residents pain LPN#500 revealed STNA#402 told her 40 minutes ago and she knew it was 40 minutes ago because she looked at the clock but could not get her pain pill because she was busy doing an admission. She stated she knew her pain pill was scheduled at noon. When asked what pain pill the resident needed she verified it was Oxycodone HCL to be given every 6 hours straight. When asked if the resident was sleeping would she give the Oxycodone LPN#500 said if the resident was sleeping they must not be in pain so no she would not wake them to give the pain pill even though the order stated every six hours. When RN#600 was asked the same question she replied if the physician order stated the pain pill was to be given four times a day then if the resident was sleeping she would need to wake the resident to administer the pain pill as that helped keep the resident's pain under control. At 12:14 P.M. LPN#500 said she was going to give Resident #40 her pain pill. Interview was conducted on 01/23/20 at approximately 12:29 P.M. with the Director of Nursing (DON) to review the concern with the MAR showing a routine pain medication was not administered by RN #601 on 01/23/20, the resident's expressed concerns about nurses not waking her to give her pain medications and the interview with LPN#500. The DON replied Resident #40 had been out of the facility on 01/20/20 for a brain procedure and the daughter had expressed to her she wanted her mom to get rest so the nurse probably let her sleep to get rest. The DON verified the order for the Oxycodone HCL was to be given straight every six hours. The DON verified there was no pain medication sent with the Resident #40 nor given when she returned to the facility on [DATE]. The DON stated RN#601 was a new nurse and she would educate her about following the doctor's order, and that she would look into possibly changing the administration times for Resident #40 so she did not have to be woke up. Record review was conducted of the facility policy titled Pain Management and Pain Protocol, dated 05/21/15. The policy stated the facility would ensure pain management for any resident identified as having a potential for pain per the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365814 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365814 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cortland Center 369 N High Street Cortland, OH 44410 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to store foods brought in from outside the facility for the residents were under sanitary and safe conditions. This had the potential to affect all 38 residents ( #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#12,#13,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#28,#29,#31,#32,#33,#34,#3 and also affected Resident #204 residing on the Walnut and Maple units in the facility. The facility census was 56. Findings included: Interview was conducted from 9:23 A.M. to 9:25 A.M. on 01/23/20 with State Tested Nursing Assistant (STNA) #400 and STNA #401 who revealed if foods are brought in from family and visitors they are to write the resident's name on it, the date it was brought in and place the food in the refrigerator in the employee break room for those residents who resided on the Maple and Walnut units and for those residents who resided on the Cherry unit those items are stored in the kitchenette fridge on the Cherry unit. Interview was conducted on 01/23/20 at 9:36 A.M. with Dietary Manager (DM) #800 who revealed if visitors and family bring food in for the residents it is to be kept in the refrigerator in the employee break room for residents on Maple and Walnut units and in the kitchenette fridge on the Cherry unit. Observation was conducted on 01/23/20 from 9:37 A.M. to 9:51 A.M. with Registered Dietitian (RD) #900 of the refrigerator freezer unit located off the Maple and Walnut units in the employee break room where resident food was stored. There was no temperature log on or around the freezer for January 2020 and that was verified with RD #900 at 9:37 A.M. The top freezer portion of the unit contained an internal thermometer reading at 14 degrees Fahrenheit (F). The bottom floor of the freezer unit was heavily coated with food particles, brown and yellow sticky substances as if it had not been cleaned recently. Within the freezer portion were two pints of ice cream from a popular creamery dated 04/24 and labeled with Resident #204's last name, a cup of unlabeled, white ice cream with nuts and a heavy accumulation of freezer frost on top of it, an unlabeled piece of pie from a popular fast food restaurant and an unlabeled, half full large, clear, plastic cup of brown substance with a plastic straw frozen within the substance. In the refrigerator section there was an internal thermometer reading at 38 degrees F. There were multiple outdated and compromised food items and items that were not labeled with a name and/ or date as follows: a box of pizza with Resident #17's name but no date, on a Styrofoam plate that was open to air there was what appeared to be an approximate one cup portion of cheese potato with two spots of black, fuzzy mold growth on it, a metal fork that was stuck to the foam plate and no name or date. That plate was sitting on top of yogurt containers labeled for Resident #22; a large Styrofoam cup filled with a pink substance without a name or date, a small foam box contained pasta in red sauce and a yellow pie-type dessert with whip topping dated 01/10/20 looked like it had a shiny biofilm on the filling part of the dessert. There was a bag of seven fresh oranges covered with brown spots on the oranges with no name or date, a plastic bag with no name or date contained two pieces of white cheese wrapped in tin foil and a plastic container of what RD#900 described as pasta Alfredo. There was a gallon of unopened apple cider with a manufacturer use by date of 11/17/19 and a half pint of milk with an expiration date of 01/03/20. Resident #22 had multiple outdated foods in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365814 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365814 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cortland Center 369 N High Street Cortland, OH 44410 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refrigerator with her name on them that were expired such as five cup-size yogurts with manufactures expiration dates of 12/19/19, 12/30/19, 01/02/20, 01/07/20, 01/09/20, one vanilla [NAME] protein shake with a manufactures expiration date of 11/09/19 and two vanilla bean protein plus shakes with facility date labels reading 10/11/19 and 11/13/19 with manufacturer expiration dates of 12/23/19 and 01/09/20. RD#900 was present throughout the observation and verified all of the above findings. RD#900 said she did not know who was responsible for making sure the food items and cleanliness of the refrigerator freezer were maintained in safe and sanitary condition. Observation was conducted on 01/23/20 at 9:53 A.M. with RD#900 of the Cherry unit fridge used to store resident foods. The unit was found to be clean with no outdated or unlabeled foods. A temperature log was up to date and documented acceptable temperatures averaging 38 degrees F. Interview was conducted on 01/23/20 at 10:07 A.M. with Dietary Manager (DM) #800 who revealed nursing services was responsible for labeling and dating the residents food before putting it in the refrigerator freezers on the units for the residents. DM#800 explained the sanitation of each refrigerator was to be maintained daily by dietary staff or housekeeping staff but there was no planned system for who the designated staff person was to check the fridge on a day by day basis. DM#800 shared she would typically check it but she was down a few positions in the kitchen and had been filling in as a cook in the kitchen. DM#800 said she did not know where the January 2020 refrigerator temperature log was for refrigerator freezer unit in the employee break room. An interview was conducted on 01/23/20 at 10:19 A.M. with the Administrator to inform him of the findings and ask who was responsible to maintain the refrigerator freezer units. The Administrator revealed he was not sure of who should have been doing it but would find out. Record review was conducted of the facility policy titled Food Brought in From Outside the Facility, date revised 02/25/19. The policy stated food would be stored in a clean, sealed container labeled with the name of the food item, resident name, dated and placed in a non-dietary refrigerator. Food dated by facility staff will be discarded within seven days from the date mark. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365814 If continuation sheet Page 4 of 4