Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Cortland Center during CMS and state inspections, most recent first.
A resident with dementia, ESBL history, chronic wounds, a PEG tube, and total incontinence was ordered for Contact Precautions related to ESBL but had no corresponding care plan for Contact Precautions or EBP for an extended period. Despite staff claims that the resident had been changed to EBP, there were no physician orders documenting a change from Contact Precautions until late in the course, and a Contact Precaution sign remained on the door while staff reported the resident was on EBP. Observations and video footage showed an LPN administering PEG medications without an isolation gown, and the resident’s daughter reported that staff often did not wear gowns or consistently use gloves, with PPE bins in the room either absent for one to two weeks or present but empty. The maintenance/housekeeping supervisor stated he had not supplied PPE bins recently and relied on nursing to notify him of transmission-based precautions, while the DON and an RN acknowledged that the care plan lacked transmission-based precaution interventions until they were added later, demonstrating a failure to follow the facility’s EBP policy for high-contact care of a high-risk resident.
A nurse provided wound care to a resident on enhanced barrier precautions without wearing a gown, despite facility policy and posted signage requiring this PPE. The nurse performed hand hygiene and changed gloves but omitted the gown, a lapse confirmed after the procedure. This failure affected one resident directly and had the potential to impact all residents under enhanced barrier precautions.
Failure to Implement and Maintain Appropriate Transmission-Based Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain appropriate transmission-based precautions for a resident with a history of ESBL in the urine and multiple high-risk conditions. The resident was admitted with diagnoses including dementia, saddle pulmonary embolus with acute cor pulmonale, urinary tract infection, and ESBL resistance. Physician orders dated 12/25/25 placed the resident on Contact Precautions/Isolation related to ESBL, with orders active through 01/29/26. However, the resident’s care plan from 12/25/25 through 01/28/26 did not include any care plan problem or interventions related to Contact Precautions or Enhanced Barrier Precautions (EBP), despite the active orders and the resident’s high-risk status, including chronic wounds, a PEG feeding tube, incontinence of bowel and bladder, and dependence on staff for ADLs. The resident’s urine culture collected on 01/08/26 and reported on 01/11/26 showed less than 10,000 CFU/mL of two groups of gram-negative rods with no work-up, and progress notes documented that the finalized results were faxed to the infectious disease physician and primary care physician. The medical record from 01/11/26 through 01/29/26 did not show any physician orders changing the resident from Contact Precautions to EBP, even though staff later reported that the resident had been changed to EBP after completion of antibiotics near the end of December. On 01/29/26, a physician order was entered for EBP every shift, but there was still a Contact Precaution sign on the resident’s door. Interviews with nursing staff revealed confusion and inconsistency: an LPN and an RN stated the resident was on EBP and that staff wore appropriate PPE, while another RN stated the resident had been on Contact Precautions at the hospital and on admission but was now on EBP. Review of orders confirmed there had been no prior order to discontinue Contact Precautions and initiate EBP until 01/29/26. Direct observations and video footage further demonstrated failures in implementing ordered precautions. Camera footage from 01/26/26 showed an LPN administering medications via the resident’s PEG tube without wearing an isolation gown. On 01/29/26, observation of the resident’s room showed a Contact Precaution sign on the door and two clean, empty PPE bins that had just been brought in that morning, with no PPE inside. The resident’s daughter reported that staff did not wear gowns and did not always wear gloves when providing care, and that gowns were first used the day before. She also provided video showing a nurse providing care without an isolation gown. The maintenance and housekeeping supervisor stated he had not supplied PPE bins to the room for at least one to two weeks and suggested housekeeping may have believed the resident was no longer on transmission-based precautions, as they rely on nursing staff to inform them. The DON confirmed there was no evidence in the care plan from 12/25/25 through 01/28/26 of any care plan for Contact Precautions or EBP, and that an EBP intervention was only initiated on 01/29/26. Facility policy on EBP required appropriate signage, PPE use (gown and gloves) for high-contact care activities, and visitor education, which were not consistently implemented for this resident. The facility’s Enhanced Barrier Precaution policy, revised 05/19/25, specified that EBP are intended to prevent transmission of MDROs via contaminated hands and clothing of healthcare workers during high-contact activities, and that high-risk residents include those with chronic wounds and indwelling devices such as PEG tubes. The policy required staff to don gown and gloves for high-contact care activities such as dressing, bathing, transferring, hygiene, changing linens and briefs, toileting assistance, device care, and wound care, and to remove PPE before exiting the room or care area. It also required signage indicating the type of precautions and instructions for visitors to stop at the nurse’s station before entering, along with visitor education on PPE use. The documented observations, interviews, and record review showed that these policy requirements were not consistently followed for this resident, resulting in the cited infection control deficiency. The DON reported she was filling in for the Infection Preventionist, who was newly hired and had not yet assumed the role, and that she herself was newly hired and still learning infection prevention. An RN responsible for wound care and MDS stated she discovered on 01/29/26 that the resident had not been changed from Contact to EBP despite the negative ESBL result and then wrote the EBP order that day. Staff accounts conflicted regarding when the resident’s precautions had changed, and the lack of corresponding orders, care plan updates, consistent signage, PPE availability, and observed PPE use during care all contributed to the failure to ensure appropriate transmission-based precautions for this resident. This deficiency was investigated under Master Complaint Number 2728869 and was based on observation, interview, record review, review of camera video footage, and facility policy review, demonstrating that the facility failed to ensure the resident had appropriate transmission-based precautions implemented as ordered and as required by its own EBP policy.
Failure to Use Required PPE During Wound Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a registered nurse provided wound care to a resident who was under enhanced barrier precautions without wearing a gown, as required by facility policy and the signage posted on the resident's door. The nurse performed hand hygiene and changed gloves appropriately during the procedure, but failed to don a gown at any point, despite the clear instructions for personal protective equipment (PPE) use for residents on enhanced barrier precautions. The nurse acknowledged after the procedure that a gown was not worn and confirmed the presence of the PPE signage. The resident involved had diagnoses including chronic obstructive pulmonary disease, hypertension, and heart failure, and was care planned for impaired skin integrity with wounds on the left breast and neck. The resident required extensive assistance with all activities of daily living and had moderate cognitive impairment. This lapse in infection control practice affected one resident directly but had the potential to impact all 29 residents who were ordered enhanced barrier precautions at the facility.
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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) |
|---|---|---|---|---|
| Ohio Living Lake Vista | 0.4 mi | ★★★★★ | 8 | 0 |
| Concord Care Center Of Cortland | 4.6 mi | — | 0 | 0 |
| Shepherd Of The Valley Howland | 5.2 mi | ★★★★★ | 0 | 0 |
| Warren Nursing & Rehab | 5.7 mi | ★★★★★ | 51 | 1 |
| Gillette Nursing Home | 5.9 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.