Cortland Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of camera video footage and facility policy review, the facility failed to ensure Resident #41 had appropriate transmission-based precautions implemented. This affected one (Resident #41) out of three residents reviewed for infection control. The facility census was 62.Findings include:Review of Resident #41's medical record revealed an admission date of 12/25/25 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, saddle embolus of pulmonary artery with acute cor pulmonale, urinary tract infection and extended spectrum beta lactamase (ESBL) resistance.Review of Resident #41's physician orders dated 12/25/25 revealed Contact Precautions/Isolation related to ESBL, every day shift and night shift. The orders were active from 12/25/25 through 01/29/26.Review of Resident #41's care plan dated 12/25/25 through 01/28/26 did not reveal evidence Resident #41 had a care plan related to Contact…

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 record review, staff interview and facility policy review, the facility failed to ensure accurate weights were obtained for Resident #31 and Resident #46. This affected two (Residents #31 and #46) of six residents reviewed for nutrition. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia, intellectual disabilities, gastro-esophageal reflux, deficiency of B vitamins, hyperlipidemia, [NAME] crisis, depression, dysphagia, and intestinal malabsorption. Review of Resident #31's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #31's cognition was intact and was independent for eating. Resident #31 was 58 inches tall and weighed 115 pounds and had a weight loss of five percent in the last month that was not physician prescribed. Resident #31 was on a mechanically altered therapeutic diet. Review of the Dietary Progress Note dated 05/12/25 revealed…

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, interview, record review and review of facility policy, the facility failed to ensure Resident #162 had a physician's order for oxygen. This affected one (Resident #162) out of one resident reviewed for respiratory care. This had the potential to affect 18 (Residents #2, #4, #7, #10, #12, #17, #18, #28, #32, #39, #40, #44, #46, #48, #53, #113, #166, and #168) identified by the facility on oxygen. The facility census was 62. Findings include: Review of the medical record for Resident #162 revealed an admission date of 06/20/25 with diagnoses including fracture of right femur, hypertension, chronic kidney disease, and altered mental status. Review of Pulmonologist #901's progress note dated 06/19/25 (while in hospital) revealed Pulmonologist #901 consulted due to pleural effusions and noted Resident #162's oxygen saturation level (percentage of oxygen in the blood) was 99 percent, and she had decreased breath sounds to her lung bases. He recommended oxygen but there was no specified route or…

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 record review, observation, interview, and facility policy review, the facility failed to use appropriate infection control precautions while providing wound care to Resident #50 who was in enhanced barrier precautions. This affected one Resident #50 but had the potential to affect all 29 residents who were ordered enhanced barrier precautions, Residents #5, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #30, #31, #33, #36, #37, #40, #44, #46, #50, #58, #61, #63, and #64. The facility census was 64. Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/17/24. Diagnoses included chronic obstructive pulmonary disease, hypertension, and heart failure. Review of the care plan dated 06/17/24 revealed Resident #50 had impaired skin integrity on her left breast and left side of her neck. Interventions included providing wound care as ordered and enhanced barrier precautions. Review of the physician's order dated 09/16/24 revealed an order for…

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, 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. 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…

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, interview, record review, review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, and review of the facility policy the facility failed to ensure Resident #2 was able to be transferred from his bed to a padded wheelchair using a mechanical lift when he requested the transfer. This affected one resident (#2) out of three residents reviewed for transfers. The facility census was 55. Findings include: Review of Resident #2's medical record revealed an admission date of 06/06/16 with diagnoses including morbid obesity due to excess calories, congestive heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's physician orders dated 06/20/23 revealed Resident #2's preference to be up from bed around 10:00 A.M. Review of Resident #2's care plan revised 07/17/23 included Resident #2 had a self-care deficit. Resident #2 required extensive assistance with activities of daily living (ADL) and might require more or less assistance at times. Resident #2's…

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 interview, closed record review, review of the facility policy and review of the Centers for Medicare and Medicaid Services (CMS) guidance the facility failed to ensure Resident #56's eye infection was treated while she resided in the facility. This affected one resident (#56) out of three residents reviewed for infections. The facility census was 55. Findings include: Review of Resident #56's closed medical record revealed an admission date of 10/07/23, and a re-entry date of 10/09/23. Resident #56's diagnoses included Alzheimer's Disease, dementia without behavioral disturbance, and fracture of the left pubis. Resident #56 was discharged from the facility on 11/07/23. Review of Resident #56's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had moderate cognitive impairment. Resident #56 required partial assistance from another person to complete bathing, dressing, using the toilet, eating, and walking from room to room. Resident #56 used a walker. Resident #56 had…

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, interview, closed record review, and review of the facility policy the facility failed to thoroughly document the appearance of Resident #56's bilateral heel deep tissue injuries (DTI). This affected one resident (#56) out of three residents reviewed for pressure ulcer injuries. The facility census was 55. Findings include: Review of Resident #56's closed medical record revealed an admission date of 10/07/23, and a re-entry date of 10/09/23. Resident #56's diagnoses included Alzheimer's Disease, dementia without behavioral disturbance, and fracture of the left pubis. Resident #56 was discharged from the facility on 11/07/23. Review of Resident #56's progress notes dated 10/09/23 through 11/07/23 did not reveal documentation related to the appearance of Resident #56's bilateral heel DTIs (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear). Further review revealed the discharge instructions…

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 interview, observation and record review, the facility failed to ensure meals served looked appetizing and were served at palatable temperatures. This had the potential to affect all residents receiving meals from the kitchen with the exception of Residents #1 and #10 who received no nutrition by mouth. The facility census was 49. Findings include: Interview on 07/17/23 at 2:08 P.M. with Resident #3 revealed hot foods were served cold upon meal service. Interview on 07/17/23 at 2:21 P.M. with Resident #45's sister revealed while at the facility, Resident #45 did not eat the food because Resident #45 said it did not taste good. Interview on 07/17/23 at 2:32 P.M. with Resident #19 revealed the food was overcooked, soggy and terrible. Observation of a test tray on 07/17/23 at 5:45 P.M. with Dietary Manager (DM) #210 revealed the meal consisted of chicken tenders, french fries, zucchini and mandarin oranges. Temperatures were obtained with the chicken tenders revealing a temperature of 119 degrees Fahrenheit (F) and the zucchini revealing a temperature of 126 degrees F. The…

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 facility policy review, the facility failed to ensure proper hand hygiene was completed during medication administration including hand washing and wearing gloves. This affected three Residents (Residents #4, #32, and #101) out of seven residents administered medications. The facility census was 49. Findings include: Observations made on 07/19/23 from 7:59 A.M. to 12:30 P.M. of medication administration by Licensed Practical Nurse (LPN) #223, LPN #234, and LPN #265 of 25 administrations made for seven residents (Residents #4, #14, #16, #32, #35, #101 and #103) revealed LPN #223 did not perform hand hygiene before or after administering medications to Resident #4. LPN #223 was observed dispensing medication into her bare hand then placing them into a medication cup, crushing them, placing in applesauce, and then administered the medications to Resident #4. Additional observation of LPN #223 revealed she did not perform hand hygiene before or after, or wear gloves while administering insulin to Resident #101. Observation during Medication…

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 record review, observation and interviews the facility failed to store foods brought in from outside the facility for the residents were under sanitary and safe conditions. This had the potential to affect all 38 residents ( #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#12,#13,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#28,#29,#31,#32,#33,#34,#35,#37,#39,#41,#43,#44,#48,#203) and also affected Resident #204 residing on the Walnut and Maple units in the facility. The facility census was 56. Findings included: Interview was conducted from 9:23 A.M. to 9:25 A.M. on 01/23/20 with State Tested Nursing Assistant (STNA) #400 and STNA #401 who revealed if foods are brought in from family and visitors they are to write the resident's name on it, the date it was brought in and place the food in the refrigerator in the employee break room for those residents who resided on the Maple and Walnut units and for those residents who resided on the Cherry unit those items are stored in the kitchenette fridge on the Cherry unit.…

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 record review, observation and interviews the facility failed to ensure Resident #40 received adequate pain management when routine pain medication was not given per a physician order. This affected one of three residents reviewed for pain (Resident #40). The facility census was 56. Findings included: Record review was conducted for Resident #40 who was admitted to the facility on [DATE] with diagnoses including low back pain, neuropathy, systemic lupus, fibromyalgia, chronic kidney disease and brain tumor. The Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact, needed extensive assistance by staff for bed mobility, transfers, toileting and hygiene, was on a scheduled pain medication regimen and took opioids daily. The Plan of Care with a date initiated of 12/11/19 identified Resident #40 had a problem with generalized pain and listed interventions as administer pharmacological interventions as indicated per physician order, assess for verbal and nonverbal signs of…

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.