Cortland Acres Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cortland Acres Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF805Mar 12, 2025

  Based on observation, record review, resident interview, and staff interview, the facility failed to provide each resident food prpared in the form to meet their individual needs for Resident's #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. This created an immediate jeopardy situation due to the risk of choking and aspiration. Resident Identifiers: #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. Facility census: 91. Findings included: a) Resident #12 On 03/03/25 at 3:18 PM, Resident #12 stated she had difficulty eating the food, especially meats, at the facility sometimes. She stated she had difficulty swallowing and sometimes the food makes her cough. On 03/04/25 at 12:32 PM, Resident #12 was observed eating lunch in her room. […]

• Immediate jeopardy, isolatedF689Jul 17, 2026

  Based on observation, record review and staff interviews, the facility failed to provide an environment free from accident hazards because the gap between the side rail and mattress measured 5 3/4 inches, which is one (1) inch greater than the recommended 4 3/4 inch gap. This failure created an immediate jeopardy situation and had the potential to cause fatal entrapment. In addition, the facility failed to provide an environment free from accident hazards by not having fall prevention measures in place for Resident #94 and not ensuring the sharps container was changed at the appropriate level. This failed practice was discovered during the Long-Term Care Survey process. Resident identifiers: #47, #94. Census: 92. […]

• Immediate jeopardy, isolatedF678Mar 12, 2025

  Based on closed record review, policy review, review of facility investigation and staff interview, the facility failed to ensure Resident #89 received Cardiopulmonary resuscitation (CPR) as resident requested and physician ordered when found pulseless, not breathing and skin pale and warm to the touch. The State Agency (SA) found this failure rose to the level of an Immediate Jeopardy This failed practice was true for Resident #89 but had the potential to affect 32 residents who requested CPR and had a physician order for CPR. Resident identifier: #89. Facility Census: 91. Findings included: a) Resident #89 Resident #89 was admitted on [DATE] with diagnoses of Diabetes, dementia, seizure disorder, coronary artery disease and high blood pressure. […]

• Actual harm, isolatedF684Jul 17, 2026

  Based on family interview, record review, and staff interviews, the facility failed to assess a resident after a fall that led to a recurrence of a left arm fracture requiring surgical intervention. This was discovered during the complaint investigation process. Census: 92 Resident identifier: #102Resident #102An interview with Rehab Manager #96 on 07/16/26 at 11:05AM, she states Resident #102 fell twice in therapy and provided therapy notes from those falls.Record review completed on 07/16/26 revealed the following Physical Therapy (PT) note. The 05/11/26 physical therapy note reads as follows: [Resident #102] lost balance and was supported per Physical Therapist (PT) via gait belt and manual support at left arm briefly. Pt complained of pain in left arm and provided ice in room. […]

• No harm, potential for more than minimal, patternF584Jul 17, 2026

  Based on observation and staff interview the facility failed to provide a clean homelike environment by having visibly soiled and unkempt recliners for residents on the memory unit(B-wing) setting area. This failed practice has the potential to affect more than an isolated number of residents on the unit. Facility census: 92a) During initial tour of the facility on 07/13/26 at 12:30 PM this surveyor observed two cream colored recliners and two brown colored recliners visibly unclean and unkempt in the setting area of B-wing. During an interview with the Administrator on 07/13/26 at 12:45 PM who stated, I'll get that taken care of now, we have plans to get sixteen new ones. confirming the recliners were not clean.