Guthrie Cortland Medical Center
GUTHRIE CORTLAND MEDICAL CENTER in CORTLAND, NY — inspection on March 31, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
disconnected.
The door was not repaired until 07/17/2024, three (3) days after Resident #1 eloped
jeopardy to resident health or 07/14/2024 they were notified by the 3rd floor charge nurse that Resident #1 eloped from the safety building.
They instructed Registered Nurse #5 to do an assessment to ensure the resident had no injuries.
The Director of Nursing reviewed the facility video footage and stated the 3rd floor door
when they reviewed it, but stated Security gave the footage to them. Resident #1 had exit seeking behaviors and was assessed as a high risk for elopement.
The Director of Nursing stated after the incident, a stretcher was placed in front of the 3rd floor door in addition to the yellow accordion style barrier until the door was fixed.
They did not know the outside vendor did not repair the door until 07/17/2024.
They stated Resident #1 was placed under constant supervision after the incident and staff were educated on elopement and exit seeking behaviors.
During an interview on 02/05/2026 at 2:14 PM, Certified Nurse Aide #11 stated on 07/14/2024 Resident #1 was exit-seeking all day, all of the time while they were working. Resident #1 constantly wandered in and out of resident rooms, near the doors, tried to enter the medication rooms, and was constantly trying to exit the facility.
The resident was not on any special watches before the elopement; staff just knew to watch the resident all the time and redirect them. On 07/14/2024, the resident went missing.
Staff were not aware the stairwell door was broken.
Certified Nurse Aide #11 stated they assisted with searching for the resident, the resident was found outside near the front of the building and was returned to the unit.
After the incident, they placed a stretcher in front of the broken door to keep the resident from exiting again and they had to monitor the resident closely so they would not climb over the stretcher.
They did not have the staff to do a 1:1 (one to one) with the resident.
They were not aware of any repairs to the door.
Security accompanied the resident back to the unit with staff and stated the alarm on the door did not work.
They did not recall when the door was fixed.
New York Code Rules & Regulations: 415.12(h)(2).__________________________________________________________________Immediate Jeopardy past non-compliance was identified, and the Administrator on Record was notified on 02/06/2026 at 2:32 PM.
The facility is currently in compliance.
The facility provided verification the following corrective actions were completed:-Resident #1 was immediately 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.
Education included a power point presentation and post-tests. -On 07/17/2024, all exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.