Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Guthrie Cortland Medical Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Failure to address severe weight loss and nutritional needs. Three residents with complex medical conditions had ongoing significant weight loss that was discussed in monthly weight meetings but not adequately reassessed or documented by the RD or provider. One resident’s recommended protein supplement was not found on the MAR/TAR or in a physician order, and provider notes for the residents did not show that the severe weight loss was addressed.
A resident with a colostomy, urostomy, DM, insulin use, anticoagulant use, and opiate use did not have documented orders for changing either ostomy appliance, and the care plan did not include key diagnoses or high-risk meds. Staff and the resident reported the facility lacked colostomy supplies, so urostomy bags were used for the colostomy, and no ostomy supplies were found in the utility or med room. The facility also did not document notifying the provider after a low BP reading of 82/58.
Cold and Unpalatable Meal Service: A resident received a lunch tray with chicken tenders measured at 114 degrees Fahrenheit and described as chewy, while 10 anonymous residents reported that the food was cold during a resident council meeting. Facility records required hot foods to be held and served at 135 degrees Fahrenheit, and an FSD stated hot food should be served at that temperature and be palatable.
A resident returned from the ED with a C. difficile diagnosis and instructions for vancomycin, but the nurse did not notify the provider or obtain the discharge paperwork. The antibiotic order was not entered until five days later, and staff interviews confirmed the ED visit and treatment plan were not communicated to the NP in a timely manner.
A resident with ESRD, DM, and dependence on renal dialysis received hemodialysis at an outside center, but the facility had no documented physician order for dialysis, pre/post dialysis assessments, or vascular access monitoring. The resident had a right chest Permacath, yet staff could not confirm consistent documentation of site checks, and the handoff record lacked some pre- and post-dialysis evaluations.
The facility failed to store food in accordance with professional standards for food service safety, as ice was observed dripping from the compressor onto food in walk-in freezer #3. Despite being aware of the issue for at least a year, effective action had not been taken to resolve it, posing a potential risk to food safety.
The facility failed to ensure nursing staff had the appropriate competencies to manage an external catheter device for a resident with acute kidney failure and difficulty walking. There was no medical order for the device, and the care plan did not include its use. Staff expressed uncertainty about the proper care and maintenance of the device, and there was no documented evidence of staff education on the device.
The facility failed to ensure proper labeling and storage of insulin in the 3rd floor Team 1 medication cart, resulting in an insulin pen and vial without opened dates and an expired insulin pen. The LPN, RN Unit Manager, and DON acknowledged the importance of proper labeling and checking expiration dates, but these practices were not consistently followed.
The facility did not ensure the results of the most recent survey and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Survey results were found in locations that required staff assistance to access, and there were no notices of their availability in prominent areas. Interviews with staff and residents confirmed the lack of accessibility and proper signage.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Address Severe Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to ensure that residents with altered nutritional status maintained acceptable nutritional parameters. Three residents had severe weight loss that was not adequately addressed by the medical provider, and their nutritional needs were not reassessed by the registered dietitian after significant declines in weight were identified. The report states that this failure resulted in Immediate Jeopardy for the three residents reviewed and placed all residents with altered nutritional status at risk for serious harm, serious injury, serious impairment, or death. One resident with heart failure, chronic kidney disease, and anxiety had documented progressive weight loss over several months, including repeated severe losses. Although the resident was discussed in monthly weight meetings and had a nutrition assessment that noted risk for malnutrition, there was no documented evidence that the registered dietitian reassessed nutritional needs after the severe weight loss continued. Physician and NP progress notes described the resident as stable or at risk for malnutrition, but the severe weight loss was not documented as addressed. The resident also had significant muscle wasting noted in provider documentation. A second resident with Parkinson’s disease, dysphagia, and dementia had repeated significant and severe weight loss despite being on a mechanical soft diet and having a care plan that identified risk for malnutrition. The resident refused oral nutritional supplements, and the dietitian documented continued monitoring and dietary preferences, but there was no documented evidence of reassessment after subsequent severe weight loss. Provider notes described the resident as frail, with severe protein/calorie malnutrition and limited life expectancy, yet there was no documented evidence that the severe weight loss was addressed. A third resident with kidney disease, dialysis, diabetes, colostomy, and urostomy had ongoing weight loss with multiple nutrition assessments documenting malnutrition risk and continued use of Liquacel from a prior admission. The dietitian documented that the resident would continue on Liquacel three times daily, but there was no documented physician order for the supplement and no evidence it appeared on the MAR/TAR. The resident continued to lose weight, and the dietitian later stated the resident had not been reassessed since readmission and that the resident was not meeting nutritional needs. Provider documentation did not show awareness of the severe weight loss.
Failure to follow ostomy orders, update care plan, and notify provider of low BP
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s choices for a resident with a colostomy and urostomy, diabetes, insulin use, anticoagulant use, and opiate use. The resident’s record showed orders for colostomy and urostomy care every shift, but there were no documented orders for changing either appliance. The resident stated they could care for the ostomies themself but had to ask for supplies, and that the facility was out of colostomy supplies, so their spouse ordered some online. The resident also stated they had been using urostomy bags for the colostomy site because the facility did not have colostomy bags available. The resident’s care plan addressed the colostomy and urostomy in general terms, but it did not include the specific type of appliance, the frequency for emptying or changing the urostomy drainage bag, or the diagnoses of diabetes mellitus, insulin use, anticoagulant use, or opiate use. The resident’s MDS documented diabetes, colostomy and urostomy status, and receipt of insulin, anticoagulants, and opiates. Staff interviews confirmed that the resident was using urostomy supplies for the colostomy because colostomy supplies were not available, and that the resident had been going through multiple bags per shift. Observations of the clean utility room and medication room found no ostomy supplies. The facility also failed to document notification of the physician when the resident had a low blood pressure reading of 82/58. The vitals record showed the low blood pressure, and there was no documented evidence that the physician was notified. Staff interviews indicated that low blood pressure was considered concerning and that provider notification was expected for low readings, but no notification was documented for this event.
Cold and Unpalatable Meal Service
Penalty
Summary
The facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature during the 02/09/2026 lunch meal and during a resident council meeting in which 10 of 10 anonymous residents stated the food was cold. During a meal observation on 02/09/2026 at 12:26 PM, Resident #46 was served a lunch tray, and the original tray was tested after a replacement tray was ordered. Registered Nurse #14 verified the food temperatures at 12:26 PM, and the chicken tenders measured 114 degrees Fahrenheit and were described as chewy. The facility policy Food Safety and Infection Control, last revised 07/02/2025, documented that food and sauces were to be held at 135 degrees Fahrenheit. The 11/24/2025 Test Tray Audit form also documented that entrees, soups, and hot beverages should be 135 degrees Fahrenheit or above. During an interview on 02/02/2026 at 12:44 PM, Resident #46 stated the food was cold, there was no variety, and the quality was poor. During an interview on 02/10/2026 at 03:30 PM, the Food Service Director stated they had never heard of cold food complaints, that temperature checks were completed at the start of meal services, and that hot food should be served at 135 degrees Fahrenheit and should be palatable.
Failure to Notify Provider of Resident’s ED Return and C. difficile Diagnosis
Penalty
Summary
The facility failed to consult with the physician when Resident #6 had a significant change in physical status after returning from the emergency department with a diagnosis of clostridioides difficile diarrhea. The resident’s hospital after-visit summary instructed staff to start vancomycin 125 mg every 6 hours for 10 days, but the resident returned to the facility without discharge paperwork, and the 01/30/2026 nursing note documented that no new orders were found. The resident had diagnoses including kidney disease with dialysis, diabetes, and a colostomy, and the care plan documented colostomy-related interventions. The physician was not notified of the emergency department visit until 02/04/2026, and the vancomycin order was not entered until that date, five days after the resident returned. During interviews, the assigned LPN stated they should have called the emergency department and the provider on call but did not, and the RN manager stated the nurse assigned was responsible for contacting the emergency department and notifying the provider when discharge paperwork was missing. The nurse practitioner stated they were not made aware of the resident’s emergency department visit until 02/04/2026 and ordered the antibiotic then.
Dialysis Care and Access Site Monitoring Not Documented
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis at a community-based dialysis center. Resident #6 had diagnoses including end stage kidney disease, dependence on renal dialysis, and diabetes, and the 01/16/2026 MDS documented the resident was cognitively intact, medically complex, and required dialysis treatments. The comprehensive care plan initiated 11/25/2025 stated the resident received dialysis on Monday, Wednesday, and Friday and that the vascular access site was checked daily and as needed, but it did not specify the access site location, type, or what was to be assessed. There was no documented physician order for dialysis, pre- or post-dialysis assessments, or dialysis vascular site monitoring. The dialysis and nursing home handoff communication tool showed the resident attended dialysis on multiple dates, but there was no documented evidence of a pre-dialysis evaluation on 01/23/2026 and no documented evidence of a post-dialysis evaluation on 01/16/2026, 01/28/2026, and 02/02/2026. During interviews, staff stated the resident returned from dialysis, was taken back to bed, and later had lunch; one nurse said the resident's right chest port was checked every shift but was not sure whether this was documented, while the RN manager stated the communication sheet should be completed before and after dialysis and that if it was not completed there should be a nurse's note. During observation, the resident had a dual lumen right chest Permacath covered with a clean, dry, intact dressing, and the resident stated staff at the facility did not look at the access site and the dressing was changed at dialysis.
Ice Dripping from Compressor onto Food in Walk-In Freezer
Penalty
Summary
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 had ice dripping from the compressor onto food stored below. Observations on two separate days confirmed that ice was dripping onto various food items, including a case of bread, a gallon jug of chocolate milk, and a sheet pan of cake, with the ice in contact with the cake. The Food Service Director acknowledged the issue, stating that the ice was due to a leak from the compressor condensation and that it had been a problem for at least a year. The Executive Chef also confirmed the issue and mentioned that the freezer was cleaned and deiced monthly, but the seals were worn and could not be fixed. Maintenance had been informed, but no effective action had been taken to resolve the problem. The Facilities Supervisor stated that work orders were to be entered into an electronic system and assigned to maintenance for completion. However, they had not been notified of the ice buildup in walk-in freezer #3. Preventative maintenance records showed that the freezer had been serviced multiple times, but there was no documented evidence that the dripping ice issue had been addressed. The supervisor also mentioned that they had an app to notify them of any freezer temperatures out of range, but no such notifications had been received. The lack of proper maintenance and communication led to the continued presence of ice dripping onto food, posing a potential risk to food safety.
Lack of Competency in Managing External Catheter Device
Penalty
Summary
The facility did not ensure that nursing staff had the appropriate competencies and skill sets to manage an external catheter device for Resident #45. The resident, who had diagnoses including acute kidney failure and difficulty walking, used an external catheter device to manage urinary incontinence. However, there was no documented evidence that nursing staff possessed the necessary competencies to manage the device, and there was no medical order for its use. The comprehensive care plan did not include the use of the external urinary catheter device, and the treatment administration record lacked documentation of external catheter care and maintenance for the resident. Observations and interviews revealed that Resident #45 had been using the external urinary catheter device for a few months due to increased skin breakdown from incontinence. The resident reported that the device was usually changed daily by a nurse or a certified nurse aide, but some nurses were unfamiliar with the device and needed assistance. Certified nurse aide #7 and licensed practical nurse #9 both expressed uncertainty about the proper care and maintenance of the device, including how often it needed to be changed. Registered nurse Unit Manager #8 confirmed that the device needed to be changed every 12 hours and as needed, but there was no clear documentation or consistent practice among staff. The Director of Nursing and interim Administrator acknowledged that the external urinary catheter device should have been listed on the resident's care plan and that staff should have been documenting when the device was changed. Although registered nurse Unit Manager #8 provided education to the staff on the unit, there was no attendance record of who received the education. The lack of documented evidence of staff education and the absence of a medical order for the device contributed to the deficiency in ensuring resident safety and well-being.
Improper Labeling and Storage of Insulin
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. Specifically, the 3rd floor Team 1 medication cart contained an insulin pen and an insulin vial without an opened date, and an insulin pen that was expired. The facility's policy required medications to be dated when opened, but this was not followed. The LPN responsible for the cart could not determine when two of the insulins were opened due to the lack of dates and acknowledged that expired medications should not be used as they may not be effective. The RN Unit Manager and the Director of Nursing confirmed that nurses were responsible for checking expiration dates and proper labeling during medication administration, but this was not consistently done. The facility's policy for storing FlexPens and other insulins was not adhered to, as evidenced by the lack of opened dates and the presence of expired insulin. The RN Unit Manager and the Director of Nursing both stated that expired medications could alter the desired effect and potency, emphasizing the importance of proper labeling and checking expiration dates. Despite periodic checks by pharmacy technicians and spot checks by the Unit Manager, the deficiencies in the 3rd floor Team 1 medication cart were not identified or corrected in a timely manner.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility did not ensure the results of the most recent survey 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 found 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). There were no notices of the availability of such reports posted in prominent and accessible areas, making it difficult for residents and visitors to access them without staff assistance. During an anonymous resident group meeting, two residents stated they did not know where the previous survey results were posted. Observations over several days confirmed that the Department of Health survey results were not located in easily accessible areas such as Cedar Run, Misty Glen, or the main lobby. Interviews with staff, including the Staffing Coordinator, unit clerk, and registered nurse Unit Manager, revealed that the survey results were placed in locations that required staff assistance to access. The Director of Nursing/Acting Administrator acknowledged that the survey results were not readily accessible and lacked proper signage to inform residents and visitors of their location.
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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) |
|---|---|---|---|---|
| Cortland Park Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Crown Park Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Groton Community Health Care Ctr Res Care Fac | 9.5 mi | ★★★★★ | 25 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 14.1 mi | ★★★★★ | 14 | 0 |
| Kendal At Ithaca | 17.5 mi | ★★★★★ | 0 | 0 |
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