Guthrie Cortland Medical Center

Inspectors wroteBased on record review and interviews during the survey, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (1) of five (5) residents (Resident #1) reviewed. Specifically, on 07/14/2024 at 3:36 PM, Resident #1, who had a history of exit seeking behaviors, was at risk for elopement, and had a wander alert device, exited the facility through the 3rd floor North Hall stairwell door. The resident was found outside by a visitor approximately 15-30 minutes later and brought back into the facility by nursing and security. This resulted in Immediate Jeopardy, past non-compliance, to Resident #1, and placed them at risk for serious harm serious injury, serious impairment, and death.

Inspectors wroteBased on observations and interviews during the survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for three (3) of three (3) Residents (Residents #6, #43, and #74) reviewed. Specifically, Residents #6, #43, and #74 had severe weight loss, which was not addressed by the medical provider and their nutritional needs were not reassessed by the registered dietitian. Additionally, the registered dietitian recommended the addition of Liquacel (liquid protein supplement) for Resident #6 and there was no documented evidence the supplement was ordered. Failure to assess and address nutritional status resulted in immediate jeopardy to Residents #6, #43, and #74 and placed all residents with altered nutritional status at risk for serious harm, serious injury, serious impairment or death.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Specifically, the survey results and plan of correction were in a pink binder on a shelf behind the nursing station on Cedar Run (second floor) and in a black binder on a shelf in the dining room on Misty Glen (third floor). Additionally, there were no notices of the availability of such reports posted in areas that were prominent and accessible to the public.

Inspectors wroteBased on record review and interview during the abbreviated surveys (NY00316770 and NY00322185), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed (Residents #2 and #7). Specifically, Resident #2 had a left leg surgical wound from a below knee amputation (BKA) with 21 sutures in place and wound treatments were not completed as ordered. There was no documented evidence of ongoing monitoring of the wound and when the wound worsened, there was no documented evidence the medical provider was notified or that an assessment was completed. The resident's wound dehisced (re-opening of the incision) requiring hospitalization, debridement (surgical removal of dead tissue), and antibiotic treatment for the infection of the amputation. [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00320465) the facility failed to ensure a resident's total program of care, including medications and treatments, was reviewed by the medical provider for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 had a history of seizures and was admitted to the facility with hospital discharge orders for seizure medications. The medications were not included on the facility admission orders and the resident did not receive anti-seizure medications for 6 days. The resident subsequently had a seizure requiring hospitalization. This resulted in actual harm to Resident #1.

Inspectors wroteBased 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.

Inspectors wroteBased 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.