Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concord Care Center Of Cortland during CMS and state inspections, most recent first.
An agency RN left the facility for lunch, leaving no nurse on-site and medication carts unlocked, affecting 32 residents. A resident with hypertension and pain did not receive her morning medications on time, causing distress. The ADON/LPN failed to report or investigate the incident, and improperly signed off on medications not administered.
An Agency RN left an LTC facility for lunch, leaving no nurse on-site and medication carts unlocked, affecting resident care. A resident with hypertension and pain did not receive her morning medications, leading to distress. The facility failed to report or investigate the incident, and staff did not follow proper procedures, resulting in a deficiency.
An agency RN left an LTC facility unattended for 45 minutes, leaving medication carts unlocked and accessible to residents. The incident was not reported to the state survey agency as required. Residents were upset due to delayed medication administration, and the facility failed to investigate or document the incident properly.
An Agency RN left a facility unattended for 45 minutes, leaving medication carts unlocked, affecting 32 residents. The incident was not reported or investigated by the facility. Residents were upset due to delayed medications, and the facility's neglect policies were not followed.
A facility failed to maintain sufficient nursing staff, leading to a situation where an agency RN left the premises for lunch, leaving medication carts unlocked and unattended. This resulted in residents not receiving timely medications, with one resident expressing concern over delayed blood pressure medication. The facility also did not meet the required daily direct care hours per resident on two occasions, contributing to delays in resident care.
An agency RN left a facility unattended for 45 minutes, leaving medication carts unlocked and delaying medication administration for residents, including one with hypertension and pain. The ADON/LPN signed off on medications not administered by her, violating facility policies. The incident was reported but not investigated, highlighting a deficiency in staff competency and resident safety.
The facility failed to ensure the required members, including the DON, attended QAPI meetings at least quarterly, potentially affecting all 32 residents. Despite monthly meetings, the DON was absent from several meetings, and the facility's policy did not specify required attendees.
A resident did not receive her scheduled morning medications on time due to the absence of a nurse when an agency RN left the facility for lunch. The resident, who had a history of hypertension and pain, expressed concern about the delay, especially given her family history of stroke. The medications were eventually administered late, and the ADON improperly signed off on the MAR, violating facility policy.
Neglect Due to Nurse Absence and Unsecured Medication Carts
Penalty
Summary
The facility failed to ensure residents were free from neglect when an agency RN left the facility for lunch, leaving no other nurse on-site. This incident occurred on 09/15/24 and had the potential to affect all 32 residents residing in the facility. The RN left both medication carts unlocked and accessible to residents, which posed a significant risk, especially to those who were cognitively impaired and independently mobile. Resident #12, who had intact cognition and was scheduled to receive several medications for conditions including hypertension and pain, did not receive her morning medications on time. The resident expressed concern about not receiving her blood pressure medication due to a family history of stroke. The RN's absence and the delay in medication administration caused distress to Resident #12, who questioned the RN upon his return. The RN's response was dismissive, suggesting that 911 could be called in case of an emergency. Interviews with staff and residents revealed that the RN did not communicate his departure, and the ADON/LPN, who was responsible for covering concerns in the absence of the DON, did not file a self-reported incident or conduct an investigation. The ADON/LPN also improperly signed off on medications that she did not administer, further complicating the documentation of the incident. The facility's policies on abuse and neglect were not followed, as no investigation or report was made to the state agency.
Neglect Due to Nurse Absence and Unsecured Medication Carts
Penalty
Summary
The deficiency involved an incident where an Agency Registered Nurse (RN) left the facility for lunch, leaving no nurse on-site for approximately 45 minutes. During this time, both medication carts were left unlocked and accessible to residents, posing a potential risk to all 32 residents in the facility. The incident was not reported to the state agency as required, and no investigation was conducted by the facility. The absence of a nurse and the unsecured medication carts were observed by residents and staff, leading to concerns about resident safety and neglect. Resident #12, who had a history of hypertension, diabetes, and pain, did not receive her scheduled morning medications due to the absence of the nurse. She expressed concern about the delay in receiving her blood pressure medication, given her family history of stroke. The resident also experienced significant pain during this period, which was not addressed promptly. The situation was further exacerbated by the nurse's dismissive response to the resident's concerns about the lack of nursing coverage and the potential for emergencies. Interviews with facility staff revealed a lack of communication and understanding of responsibilities. The Assistant Director of Nursing (ADON) did not provide adequate orientation or instructions to the Agency RN, assuming he would know not to leave the facility unattended. Additionally, the ADON signed off on medication administration records for medications she did not administer, leading to inaccuracies in documentation. The facility's policies on abuse and neglect were not followed, as the incident was not reported or investigated, and residents were not protected from potential harm.
Failure to Report Staff-to-Resident Neglect
Penalty
Summary
The facility failed to report an incident of staff-to-resident neglect to the state survey agency. On a specific date, Agency RN #607 left the facility for lunch, leaving no nurse on-site for approximately 45 minutes. During this time, both medication carts were left unlocked and accessible to residents, posing a potential risk to all 32 residents in the facility. The incident was not self-reported as required by the facility's policy on abuse, neglect, exploitation, or misappropriation. Interviews revealed that the Director of Nursing (DON) was out of town, and the Assistant Director of Nursing (ADON/LPN #601) was responsible for covering any concerns. However, ADON/LPN #601 did not educate Agency RN #607 about the prohibition against leaving the facility unattended. When informed of the situation, ADON/LPN #601 did not conduct an investigation or file a self-reported incident (SRI) with the state agency. The Administrator was initially unaware of the incident and did not complete an investigation, believing ADON/LPN #601 was present at the facility during the nurse's absence. Residents expressed concerns about the lack of nursing supervision and the delay in receiving medications. Resident #12, in particular, was upset about not receiving her morning medications, which included pain and blood pressure medications. The resident expressed fear of potential health risks due to the delay. The facility's policy required all incidents of neglect to be reported and investigated, but this was not done, leading to a deficiency in compliance with regulatory requirements.
Neglect Incident Due to Nurse Absence
Penalty
Summary
The facility failed to thoroughly investigate an incident of staff-to-resident neglect involving an Agency Registered Nurse (RN) who left the facility unattended for approximately 45 minutes. During this time, the RN left both medication carts unlocked and accessible to residents, potentially affecting all 32 residents in the facility. The incident was not self-reported to the Ohio Department of Health, and no investigation was conducted by the facility management. Interviews revealed that the Director of Nursing (DON) was out of town on the day of the incident, and the Assistant Director of Nursing (ADON) was responsible for addressing any concerns. The ADON was informed by a Certified Nursing Assistant (CNA) that the RN had left the facility, leaving the medication carts unlocked. Despite being aware of the situation, the ADON did not conduct an investigation or file a self-reported incident (SRI) with the state agency. The Administrator was also unaware of the incident until later and did not initiate an investigation. Residents expressed concerns about the RN's absence and the delay in receiving their medications. One resident reported experiencing pain and anxiety due to not receiving her morning medications, which included pain and blood pressure medications. The RN, who was a travel nurse, claimed he left to address his low blood sugar and was unaware that he was the only nurse on duty. The facility's policies on abuse, neglect, and reporting were not followed, as the incident was not thoroughly investigated, and the required documentation was not completed.
Nursing Staff Shortage and Medication Delays
Penalty
Summary
The facility failed to ensure sufficient nursing staff, resulting in a situation where there was no licensed nurse on the premises. On 09/15/24, Agency RN #607 left the facility for lunch, leaving the medication carts unlocked and unattended, and did not inform the Certified Nursing Assistant (CNA) #603 or any other staff member. This left the facility without a nurse, as RN #607 was the only nurse on duty at the time. The Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #601 was not present at the facility and was unaware that RN #607 had left until she was informed by the Housekeeping Supervisor. The Director of Nursing (DON) was out of town and did not file a State Reportable Incident (SRI) or conduct an investigation into the incident. Residents were directly affected by this deficiency. Resident #6 observed the absence of a nurse and reported feeling unsafe, while Resident #12 did not receive her morning medications, including pain and blood pressure medications, until much later. Resident #12 expressed concern about the potential health risks due to the delay in receiving her medications, especially given her family history of stroke. The lack of communication and the absence of a nurse led to distress among the residents, with Resident #12 confronting RN #607 upon his return. The situation was reported to the Ombudsman by Resident #6, but no follow-up was conducted by the facility. Additionally, the facility did not meet the minimum daily direct care requirement of 2.50 hours per resident on 09/15/24 and 09/21/24. The staffing tool revealed that on 09/15/24, the facility only provided 2.35 hours per resident, and on 09/21/24, 2.42 hours per resident. The facility's assessment tool indicated a plan for two nurses and four aides per day, but on 09/15/24, there was only one aide from 6:00 A.M. to 11:00 A.M. to care for 30 residents. This understaffing contributed to delays in resident care, including incontinence rounds and assistance with meals, further exacerbating the deficiency in care provided.
Nursing Staff Inadequacy Leads to Resident Care Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff with appropriate competencies, leading to a significant deficiency in resident care and safety. On a particular day, an agency RN left the facility for lunch, leaving no nurse on duty for approximately 45 minutes. During this time, medication carts were left unlocked and accessible to residents, posing a potential risk to all 32 residents in the facility. The RN did not communicate his departure, and the Assistant Director of Nursing (ADON)/LPN was not present to oversee the situation, resulting in a lack of supervision and potential neglect. Resident #12, who had multiple medical conditions including hypertension and pain, did not receive her scheduled medications on time due to the absence of the RN. This resident expressed concern about the delay in receiving her blood pressure medication, given her family history of stroke, and reported experiencing significant pain. The RN's response to her concerns was dismissive, further exacerbating the resident's distress. The ADON/LPN later signed off on the medication administration records, despite not being present or administering the medications herself. The facility's policies on medication administration and abuse prevention were not adhered to, as evidenced by the lack of timely medication administration and the failure to investigate and report the incident as potential neglect. The facility's contract with the agency did not specify the training or responsibilities of agency staff, contributing to the RN's lack of awareness about not leaving the facility unattended. The incident was reported to the Ombudsman, but no follow-up investigation was conducted by the facility, highlighting a significant oversight in addressing and rectifying the deficiency.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members, including the Director of Nursing (DON), attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. This deficiency was identified during a complaint investigation and had the potential to affect all 32 residents residing in the facility. A review of the attendance sheets for the QAPI meetings from October 15, 2023, to September 11, 2024, revealed that the facility met monthly; however, the DON was not present at the meetings on February 14, March 18, April 25, May 11, June 13, and July 22, 2024. An interview with the President of Operations and the Administrator confirmed that the DON failed to attend these meetings, and they were unable to provide a reason for her absence. The facility's policy on the QAPI program, dated February 2020, stated that the facility should develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program focused on indicators of the outcome of care and quality of life of the residents. The administrator was responsible for ensuring compliance with federal, state, and local regulatory agency requirements. The policy indicated that the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities, but it did not specify which members were required to attend the meetings.
Significant Medication Error Due to Nurse Absence
Penalty
Summary
The facility failed to ensure that Resident #12 was free from significant medication errors. On 09/15/24, Resident #12 did not receive her scheduled morning medications, which included medications for anxiety, high blood pressure, and pain, at the prescribed times of 8:00 A.M. and 9:00 A.M. This was due to the absence of a nurse in the facility when Agency RN #607 left for lunch, leaving no nurse on duty. Resident #12, who had intact cognition and a history of hypertension and pain, expressed concern about not receiving her medications, especially given her family history of stroke due to high blood pressure. The incident occurred when Agency RN #607, a travel nurse working his first shift at the facility, left the premises to address his low blood sugar by getting food, unaware that he was the only nurse on duty. During his absence, residents, including Resident #12, were left without their morning medications. Upon his return, Resident #12 questioned him about the delay, and he responded dismissively, suggesting that 911 could be called in case of an emergency. The medications were eventually administered around 12:30 P.M., but the exact time was not documented due to the nurse's inability to sign off electronically. The Assistant Director of Nursing (ADON)/LPN #601, who was not present during the medication administration, signed off on the Medication Administration Record (MAR) for the medications that were not administered by her. This action violated the facility's policy, which requires the individual administering the medication to sign off on the MAR. The facility's policy also mandates that medications be administered within one hour of the prescribed time, which was not adhered to in this case. The deficiency was investigated under Master Complaint Number OH00157987.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cortland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Manor | 3.8 mi | ★★★★★ | 8 | 0 |
| Cortland Center | 4.6 mi | ★★★★★ | 1 | 0 |
| Ohio Living Lake Vista | 4.9 mi | ★★★★★ | 8 | 0 |
| Shepherd Of The Valley Howland | 7.7 mi | ★★★★★ | 0 | 0 |
| Warren Nursing & Rehab | 8.7 mi | ★★★★★ | 51 | 1 |
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