Guthrie Cortland Medical Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of one (1) resident (Resident #6) reviewed. Specifically, -Resident #6 required a colostomy (a surgical opening in the abdomen that allows stool to pass out of the body) and did not have orders for changing the appliance and was not provided with appropriate colostomy supplies.-Resident #6 required use of a urostomy (surgical opening in the abdomen that allows urine to pass out of the body) and there were no orders to change the appliance. -the person-centered comprehensive care plan did not include the diagnoses of diabetes mellitus and insulin use, use of an anticoagulant (blood thinner), or the use of opiates (narcotic pain medication). -the physician was not notified when the resident had low blood pressure. Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews during the recertification survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for one (1) of one (1) meal reviewed (the 02/09/2026 lunch meal) and 10 of 10 anonymous residents during a resident council meeting. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 02/09/2026 and 10 anonymous residents during a resident council meeting stated the food was cold. Findings include:The facility policy Food Safety and Infection Control, last revised 07/02/2025, documented food and sauces were held at a temperature of 135 degrees Fahrenheit.The 11/24/2025 Test Tray Audit form documented entrees, soups and hot beverages should be 135 degrees Fahrenheit or above.During a meal observation on 02/09/2026 at 12:26 PM, Resident #46 was served their lunch tray. A replacement tray was ordered, and Resident #46's original meal tray was tested. At 12:26 PM, Registered Nurse #14 verified the measured food temperatures. The chicken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and interviews during the recertification survey, the facility failed to consult with the physician when there was a significant change in the resident's physical status for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 returned from the emergency department on 01/30/2026 with a diagnosis of clostridioides difficile (a highly contagious bacteria causing diarrhea) and instructions to start vancomycin (an antibiotic) 125 milligram capsule every six (6) hours for ten (10) days and the physician was not notified. Subsequently, the antibiotic was not ordered until five days later on 02/04/2026. Findings include:The facility policy, Admission/ readmission Process of a New Resident, revised 01/23/2026, documented if a resident was admitted to the facility without discharge orders, nursing staff would contact the discharging facility. The nurse manager/ designee would discuss the resident's condition, status, and orders with the medical provider. The facility policy, Notification of Changes to Provider, effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews during the recertification survey, the facility failed to ensure that residents who required dialysis services (filtration of blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments, there was no documented evidence the resident's dialysis access site (Permacath, a central catheter) was routinely assessed, and there were no physician orders for dialysis, pre or post dialysis assessments, or dialysis vascular site monitoring.Findings include:The facility policy, Offsite Hemodialysis Care and Coordination, revised 12/31/2025, documented a continuous 24-hour communication process was maintained between the facility and the dialysis center. Before each treatment a licensed nurse monitored the resident's vital signs, weight, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 3/11/2024 - 3/15/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety in the main kitchen. Specifically, walk-in freezer #3 within the main kitchen had ice dripping from the compressor onto food that was stored below. Findings include: The facility policy Food Safety Operations and Infection Control revised 8/20/2023 documented all walk-in refrigerators and freezers have temperature dials and thermometers inside. The temperature of the thermometers and condition of the food is monitored daily. The following observations were made: - on 3/11/2024 at 9:58 AM, walk-in freezer #3 had ice dripping from the compressor onto cases of food product stored below. - on 3/12/2024 at 12:14 PM, walk-in freezer #3 had ice dripping from the compressor onto a case of bread, a gallon jug of chocolate milk, and a sheet pan of cake partially covered with plastic wrap. The ice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 used an external catheter device (a soft flexible wick that draws urine away from the body into a sealed canister using suction) to manage urinary incontinence and there was no documented evidence nursing possessed the competencies and skill sets to manage the device. Additionally, there was no medical order for use of the device. Findings include: The facility policy Compliance Training and Education revised 1/25/2023 documented employees were to be provided with ongoing training and education to mitigate noncompliance. Training/education were completed upon hire, annually, and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00294915) surveys conducted 3/11/2024-3/15/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #34) reviewed. Specifically, Resident #34's prepared medications were left in a cup unattended on their bedside table for over 2 hours and licensed practical nurse #1 documented the medications were administered at 8:00 AM when they were not. Additionally, licensed practical nurse #1 crushed extended release medications (potassium chloride extended release and pantoprazole delayed release). Findings include: The facility policy Medication Administration revised 12/1/2020 documented the nurse should stay with the resident until the medication was swallowed and should not leave medications at the bedside. All medications were signed for at the time of administration after the resident had taken the medications. Medications could be administered an hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 3 medication carts (3rd floor Team1 cart) reviewed. Specifically, the 3rd floor Team 1 medication cart contained 1 insulin pen and 1 insulin vial without an opened date, and 1 insulin pen that was expired. Findings include: The facility policy Medication Storage in the Facility dated May 2018 documented medications and biologicals were stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. When the original seal of a manufacturer's container or vial was initially broken, the container or vial was dated. The nurse placed a date opened sticker on the medication and entered the new date of expiration. The expiration date of the vial or container was 30 days unless the manufacturer recommended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview during the abbreviated survey (NY00316770), the facility did not ensure alleged violations were thoroughly investigated and did not prevent further potential abuse/neglect while the investigation was in process for 1 of 7 residents (Resident #2) reviewed. Specifically, Resident #2 reported their wound treatments were not completed as ordered on 3 occasions and the investigation was not thorough and complete. The facility did not identify all involved staff and did not immediately implement a plan to protect residents and prevent reoccurrence. Findings include: The facility policy Investigation-Resident Abuse dated 3/1/2019 documented if there was reasonable cause to believe a person receiving care had been physically abused, neglected, or mistreated, the facility would conduct a thorough investigation. The investigation would be carried out immediately, all witnesses would be interviewed, and a record of the interviews would be in written form. The investigation of potential abuse would include a plan to prevent reoccurrence. The facility policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interview during the recertification and abbreviated surveys (NY00267452) conducted from 12/15/21-12/17/21 the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 resident (Resident #13) reviewed. Specifically, the resident and the resident representative requested the resident's personal laundry be done by the resident representative and the facility denied the request. In addition, when the facility began permitting resident representatives to do laundry again, there was no documented evidence staff followed-up with the resident representative regarding the change in the policy. Findings include: The facility policy Resident Personal Laundry reviewed 10/2020 documents when clothing is removed from the resident it will be placed in the laundry bags in the hallway. Once full they are put in the dirty utility room. The Housekeeping Linen Personnel will be responsible for sorting resident's laundry and returning the clean linen to each resident's room. Washer/dryer is available on second and third…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.