Inspection·June 26, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #46 was admitted to the facility on [DATE]. Medical diagnoses included myocardial infarction, hyperlipidemia, atrial fibrillation, ventricular septal defect, acute respiratory failure, peripheral vascular disease, abdominal aortic aneurysm, type two diabetes, pressure ulcer sacral, dysphagia, cognitive communication deficit, anxiety, depression, and hypotension. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #46's cognition was intact and was independent for eating. Resident #46 was 61 inches tall and weighed 121 pounds. Resident #46 had a weight loss of 5 percent or more in one month and was not on a physician prescribed weight loss diet. Resident #46 was on a therapeutic diet. Review of the physician order dated 04/15/25 with no end date revealed Resident #46 was to be on weekly weights. Review of the facility EMR, Vital Signs and Weight Record, revealed Resident #46 weighed 121.1 pounds on 04/16/25, 118 pounds on 05/14/25, 120.5 pounds on 05/21/25, 112 pounds on 05/27/25 and 121.9 pounds on 06/04/25. Interview with Resident #46 on 06/25/25 at 9:30 A.M. revealed she was aware she had lost weight and did not like the oral nutrition supplements or diet provided. Interview with Licensed Practical Nurse (LPN) #541 on 06/25/25 at 12:03 P.M. revealed all weekly and monthly weights were only documented in the electronic medical record after the nurse aides obtained the weekly or monthly weight. Interview with RD #573 on 06/25/25 at 1:50 P.M. revealed the nurse or dietitian could input weekly or monthly weights into the electronic medical record, and she assumed the weight input on 05/27/25 was placed in error. Interview on 06/25/25 at 3:24 P.M. with the DON verified a physician order was placed on 04/15/25 that Resident #46 was to be on weekly weights. The DON verified the weekly weight documentation was not available on other facility documents or documented in the electronic medical record for the week of 04/21/25, 04/28/25, 05/05/25, 05/26/25 and 06/16/27. Review of the facility policy titled Weights Policy, dated May 2015, revealed obtaining accurate weights was vital for nutritional assessment, and all weights for each resident including new admission, readmission, monthly and weekly were to be recorded in one central weight record such as the electronic health record and Vital Signs and Weight Record. 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 06/26/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #162 had a physician's order for oxygen. This affected one (Resident #162) out of one resident reviewed for respiratory care. This had the potential to affect 18 (Residents #2, #4, #7, #10, #12, #17, #18, #28, #32, #39, #40, #44, #46, #48, #53, #113, #166, and #168) identified by the facility on oxygen. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #162 revealed an admission date of 06/20/25 with diagnoses including fracture of right femur, hypertension, chronic kidney disease, and altered mental status. Review of Pulmonologist #901's progress note dated 06/19/25 (while in hospital) revealed Pulmonologist #901 consulted due to pleural effusions and noted Resident #162's oxygen saturation level (percentage of oxygen in the blood) was 99 percent, and she had decreased breath sounds to her lung bases. He recommended oxygen but there was no specified route or rate per the progress note. Review of the June 2025 physician orders revealed Resident #162 did not have an order for oxygen. Review of the After Visit Summary dated 06/20/25 revealed Resident #162 was in the hospital from [DATE] to 06/20/25 and was discharged to the facility with congestive heart failure instructions. The summary, under the area of oxygen therapy, revealed no specific route or rate for oxygen. Review of the oxygen saturation levels dated from 06/20/25 to 06/24/25 revealed on 06/20/24 at 7:15 P.M. Resident #162's oxygen saturation level was 92 percent on three liters per minute of oxygen, on 06/21/25 at 12:05 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/21/25 at 10:26 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/22/25 at 11:35 A.M. her oxygen saturation level was 95 percent without oxygen, on 06/22/25 at 8:02 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/23/25 at 4:15 P.M. her oxygen saturation level was 95 percent on four liters per minute of oxygen, on 06/23/25 at 11:34 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, and on 06/24/25 at 11:11 A.M. her oxygen saturation level was 94 percent on five liters per minute of oxygen. Review of the comprehensive care plan dated 06/23/25 revealed there was nothing in Resident #162's care plan regarding oxygen use. Observation on 06/23/25 at 9:45 A.M. revealed Resident #162 was lying in bed with oxygen at five liters per minute per nasal cannula. Observation on 06/24/25 at 12:22 P.M. with the Director of Nursing (DON) verified Resident #162 was lying in bed with oxygen at 4.5 liters per minute per nasal cannula. Interview on 06/24/25 at 12:22 P.M. with the DON verified Resident #162 did not have a physician's order for oxygen. She also verified the oxygen saturations levels from 06/20/25 to 06/24/25 indicated Resident #162 was on different liter flows since admission as on 06/20/24 at 7:15 P.M. Resident #162 was on three liters per minute of oxygen, on 06/22/25 at 11:35 A.M. she was without oxygen, and on 06/24/25 at 11:11 A.M. she was on five liters per minute of oxygen. She verified the other times (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 06/26/2025 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 0695 that the oxygen saturation levels were documented Resident #162 was on four liters per minute of oxygen. Level of Harm - Minimal harm or potential for actual harm Review of the nursing note dated 06/24/25 at 2:33 P.M. authored by the DON revealed she contacted Primary Care Physician (PCP) #900 who confirmed she had given an order upon admission for Resident #162 to be on four liters per minute if oxygen per nasal cannula continuously. Residents Affected - Few Review of the facility policy labeled, Oxygen Administration (All Routes) revealed licensed clinicians with demonstrated competence would administer oxygen per the specific route as ordered by the physician. The policy revealed, under the procedure, the nurse would verify the physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365814 If continuation sheet Page 4 of 4