Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, facility policy review, and interview the facility failed to ensure Resident #24's
left foot was assessed after State Tested Nursing Assistant (STNA) #610 bumped her foot on her bedroom
doorframe, failed to complete documentation of the incident, and failed to ensure the physician was notified
timely. This affected one resident (#24) of three residents reviewed for injuries. The facility census was 51.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #24 revealed an admission date of 03/29/21 with diagnoses
including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis.
Review of the care plan dated 06/13/23 revealed Resident #24 had a self-care deficit and was dependent
on staff for activities of daily living. Interventions included custom power chair, mechanical lift with transfers,
and assist with activities of daily living (ADL) including transfers.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had
intact cognition. She used a wheelchair for locomotion. She was dependent on staff assist for transfers and
bathing.
Review of the nursing notes for Resident #24 dated from 11/01/23 to 02/06/24 revealed no documentation
regarding Resident #24 bumping her left foot on the doorframe. No documented evidence of an
assessment of her left foot after STNA #610 bumped her foot, no documentation of a bruised area to her
left great toe and/or notification to the physician of the incident.
Review of the Incident Accident Log dated from 11/01/23 to 02/05/24 revealed no incidents involving
Resident #24 including staff bumping her left foot on the doorframe were contained on the log.
Review of the Bath/ Shower Sheet dated from 12/01/23 to 02/05/24 revealed no documentation Resident
#24's left foot was bumped on the doorframe while transferring her to the shower.
Review of the Weekly Skin Evaluations dated 01/09/24, 01/16/24, 01/23/24, and 01/30/24 had revealed no
documentation regarding any abnormalities to Resident #24's left great toe.
Review of the Wound Progress Note dated 02/05/24 completed by Wound Nurse Practitioner (NP) #607
revealed Resident #24 stated her left great toe was bumped and she was concerned about further bruising
to her left toes. The note revealed her left great toe was ecchymotic (bruised), stable without
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
365814
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
02/06/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
drainage, swelling and/or redness. She had no other bruising to her other digits on her left foot. She
recommended monitoring her left great toenail for signs of infection and/or instability.
Interview on 02/05/24 at 7:52 A.M. with Resident #24 revealed she was a diabetic and felt her left foot was
now permanently scarred. She revealed a few months ago STNA #610 was rushing while pushing her in
the shower chair and her left foot hit the doorframe causing injury to her foot. She then revealed a few
weeks ago the same STNA, STNA #610, hit her left foot again on her bedroom doorframe when she was
pushing her in the shower chair out of her room. She revealed STNA #610 laughed and stated, you left
enough blood for DNA (deoxyribonucleic acid). She revealed she did not find the incident funny as she was
concerned regarding injuries to her feet especially since she was diabetic. She revealed STNA #610 told
her that she had reported the incident to Licensed Practical Nurse (LPN) #606. She revealed she did not
feel LPN #606 did anything about the incident as she does not feel STNA #610 was disciplined for the
incident especially since it was STNA #610's second time hitting her foot on the doorframe causing injury.
She revealed she was upset as she did not want STNA #610 to continue to injure her feet when she gave
her showers.
Interview on 02/05/24 at 9:15 A.M. with LPN #606 revealed there was one time approximately six months or
even longer when an aide (she could not remember who) bumped Resident #24's toe while transferring her.
She revealed she could not remember the details. She revealed she was not notified of any incident
recently within the last month that was brought to her attention of any staff bumping her foot again during
care.
Observation on 02/05/24 at 10:05 A.M. of wound care for Resident #24 completed by Wound NP #607 and
Assistant Director of Nursing (ADON) / Registered Nurse (RN) #600 revealed Resident #24's had bruising
to her left great toenail. ADON/ RN #600 had revealed he was not aware she had a bruised left great
toenail.
Interview on 02/05/24 at 10:10 A.M. with Wound NP #607 revealed the left great toenail was bruised but
that the toenail was at this time secured and there were no signs of infection. She revealed she was unsure
if Resident #24 would lose her toenail and at this time she recommended the facility to monitor the area.
Interview on 02/05/24 at 3:17 P.M. with STNA #610 revealed she had worked at the facility since 08/2022.
She revealed after she had first started at the facility, she was pushing Resident #24 in a shower chair to
the shower and accidentally bumped her foot (she could not remember which foot) on the doorframe. She
revealed Resident #24's foot was bleeding and she had notified the nurse who checked and treated it. She
revealed recently approximately two or three weeks ago the same thing had happened. She revealed she
was pushing Resident #24 in a shower chair out of her room and her toe bumped the side of the doorframe.
She revealed she had checked her toe and there was no bleeding or signs of injury. She revealed she
notified the nurse but could not remember the nurses' name that she reported the incident to. She revealed
she felt the cause of bumping her foot was she was small in stature, so it was hard to control the shower
chair as she pushed it.
Interview on 02/05/24 at 3:52 P.M. with the Director of Nursing verified there was no documentation an
assessment was completed for Resident #24 after STNA #610 bumped her left great toe on the door frame,
no incident report, documentation in the nursing notes, and/or documentation Primary Care Physician #612
was notified of the incident.
Review of the personnel file for STNA #610 revealed a hire date of 08/03/22. There was no evidence
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365814
If continuation sheet
Page 2 of 3
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
02/06/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
in her file STNA #610 was re-trained on assisting residents in shower chairs to prevent injuries after the
incidents with Resident #24.
Review of the facility policy titled Resident Change in Condition, dated 07/02/21, revealed the licensed
nurse would recognize and intervene in the event of a change in resident condition. The policy revealed the
physician would be notified when there was an accident or incident involving the resident. The policy
revealed the nurse would record the information related to the change in condition and subsequent events
in the resident's health record.
This deficiency represents non-compliance investigated under Complaint Number OH00150107.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365814
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 6, 2024 survey of CORTLAND CENTER?
This was a inspection survey of CORTLAND CENTER on February 6, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CORTLAND CENTER on February 6, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.