Good Shepherd-Fairview Home INC

Based on observation, record review, and interview during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not develop care plans that describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences for (4) of four (4) residents (Residents #65, #4, #8, and #5) reviewed. Specifically, Resident #65 and #4's care plan did not include the use of anticoagulant (blood thinner) medication. Resident #8's care plan did not include the use of diabetic medications and Resident #5's care plan did not include the use of antihypertensive medications. Findings include: The facility policy, Comprehensive Care Plan, revised 7/2019, documented each discipline was responsible for the initiation and augmentation of problems with correlating goals and approaches to address care areas, to support the highest quality of care. Interdisciplinary team members were expected to have analyzed each triggered care area assessment related to their discipline and would have made care…

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 7/29/2025 to 8/1/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for one (1) of two (2) residents (Resident #5) reviewed. Specifically, Resident #5's enhanced barrier precautions were not followed, and wound care was completed without appropriate hand hygiene, clean supplies, and precautions to prevent contamination of the wound. Additionally, Licensed Practical Nurse #15 did not perform hand hygiene consistently during their medication administration between residents.Findings included: The facility policy Enhanced Barrier Precautions, revised 11/2024, documented enhanced barrier precautions were utilized to prevent the spread of multidrug-resistant organisms to residents. Gowns and gloves were to be utilized during high contact resident care activities when contact precautions did not apply. Examples of high…

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 interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of one (1) resident (Resident #8) reviewed. Specifically, Resident #8's diabetes mellitus diagnoses was incorrect in the resident's electronic medical record and was incorrectly coded in their Minimum Data Set, their morning insulin sliding scale order was not updated timely per the Endocrinologist's recommendation, the resident had a low blood sugar outside their sliding scale parameters with no documented notification to the provider, did not have maximum parameters on their sliding scales on when to notify the provider, and did not have a person-centered diabetic management care plan. Additionally, the resident did not have the recommended diabetic eye exam scheduled. The facility policy, Emergency Procedure Hyperglycemia, effective 4/2022, documented the nurse was…

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, observations, and interviews during the recertification survey conducted 7/29/2025 - 8/1/2025, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of two (2) residents reviewed (Resident #5). Specifically, Resident #5 had a pressure ulcer that was not reclassified to its proper stage once opened and they did not have their ordered protective dressing applied to their hand as ordered to maintain skin integrity. Additionally, the resident's privacy was not maintained during wound care. The facility policy, Skin-Wound Assessment and Care, effective 4/2022, documented the interdisciplinary team were to minimize pressure and risk factors to the resident's skin and ensure adequate hydration and nutrition to maintain skin integrity. A pressure ulcer means an ulcer and/or necrotic tissue overlaying a bony prominence that had been subjected to pressure, friction, 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.

Based on observations, record review, and interviews during the recertification survey conducted 7/29/2025 to 8/1/2025 the facility did not ensure a system of records and accounts of all controlled drugs was maintained for one (1) of two (2) nursing carts (Rehab Unit) reviewed. Specifically, the controlled substance accountability record was not accurately reconciled after the medication was administered to the resident for four residents.Findings include:The facility policy Controlled Medication Storage, effective 5/2018 documented controlled substances were subject to special handling, storage, disposal, and record keeping in accordance with federal, state, and other applicable laws and regulations. A controlled substance accountability record was prepared by the pharmacy/facility for controlled substance category medications including those in emergency supply. The following information was completed on the accountability form upon dispensing or receipt of controlled substance or use of controlled substance from the emergency supply: name of resident, prescription number,…

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 and interviews during the recertification survey conducted 7/29/2025 to 8/1/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of two (2) medication carts (Rehab Unit cart) and one (1) of one (1) medication rooms (Rehab Unit) reviewed. Specifically, the Rehab Unit medication cart had three multidose eye drops that were opened and expired. The Rehab Unit medication room had two single resident use medication vials that were unlabeled, there was expired flu vaccine in the medication fridge and a box of medications to be destroyed underneath the medication room sink. Additionally, the Rehab Unit medication cart was left unattended and out of sight of the licensed practical nurse during one observation.Findings include:The facility policy Medication Storage in the Facility, effective 5/2018, documented medications and biologicals would be stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply…

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 conducted 7/29/2025-8/1/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of two (2) kitchenette areas. Specifically, the 3rd floor kitchenette contained staff food items that were not properly stored, undated food items in the refrigerator, dishes were not dried properly after washing, and the air conditioning vent had debris on it.Findings include:The facility policy Unit Pantries effective 12/2024 documented dietary would check all unit pantry refrigerators and cupboards daily and discard items that were not labeled, not dated, expired, or items opened not sealed or covered properly. Unit refrigerators in the pantry were for resident items only and staff should not consume or store products in the resident refrigerators.The facility policy Sanitary Conditions effective 12/2024 documented storage areas including cupboards, shelves, and drawers were to be kept dry and clean from…

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 interview during the recertification and abbreviated (NY00329838)surveys conducted 1/16/2024- 1/19/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 5 of 5 residents (Residents #1, #24, #25, #27 and #38) reviewed. Specifically, for Residents #1, #24, #25, #27 and #38 there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives or that consents were obtained prior to bed rail installation. Additionally, on 12/13/2023, Resident #24 was found sitting on the floor next to their bed with their left arm entrapped in the bed rail resulting in abrasions to their abdomen. Findings include: The facility policy Physical Restraints, reviewed 4/21/2022, documented physical restraints were any manual method or physical mechanical device, material or equipment attached…

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 1/16/2024- 1/19/2024, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional standards and included the expiration date when applicable for 1 of 2 medication carts units (Unit 2 Long Hall medication cart) reviewed. Specifically, the Unit 2 Long Hall medication cart had 1 bottle of aspirin that was expired, 2 bottles of aspirin that did not have an expiration date listed, 1 multi-dose insulin pen that was not labeled with a resident name or an opened date, and 1 multi-dose insulin pen that was opened more than 28 days. Findings include: The facility policy Medication Storage in the Facility dated 2011 documented that stock medications would be kept separately from individually patient labeled medications. Outdated medications would be immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy if a current order exists. The facility Insulin Injection…

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, observation, and interview during the recertification survey conducted 1/16/2024-1/19/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, the main kitchen dish machine area walls were unclean; the ceiling tile metal grid was rusty; and there were expired and undated bread products. Findings include: An undated facility policy Procedures: Walls, Kitchen-Cleaning documented the procedure frequency as needed and the time required was 15 minutes per each 10 foot x 10 foot wall section. The undated facility Food Storage Guidelines documented bread on a shelf was to be discarded after 4 days, and rolls were to be discarded after the package date. The following observations were made in the main kitchen on 1/16/2024 from 9:20 AM-10:50 AM: - the dish machine area walls were unclean, and the ceiling tile grid was rusty; - there was a loaf of club wheat bread that had a best by date of 1/7/2024; and - the bread shelf in 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 and interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to ensure the New York State Department of Health (NYSDOH) was notified of a loss of service and was not in compliance with Federal, State, and Local Laws and Professional Standards. Specifically, NYSDOH was not notified of a loss of the commercial dish machine within the main kitchen according to the NYS DOH Nursing Home Incident Reporting Manual. Findings include: The NYSDOH Nursing Home Incident Reporting Manual last updated August 2016 documents the facility must report planned and unintentional concerns effecting kitchen sanitation. This section refers to situations that are planned, such as for evaluation or repair, as well as situations that are unplanned, unexpected or emergent in nature. At least one of the following elements must be present for an incident to be reportable to the NYSDOH: -Loss of service lasting or expected to last 4 or more hours. -There is no back-up system in place; or -The back-up system fails to work. -Planned or unexpected events that may…

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 interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 kitchenette refrigerator (third-floor kitchenette) and 3 of 3 juice machines (second and third-floor kitchenette and main dining room juice machines). Specifically, the air temperature of the third-floor kitchenette refrigerator was not maintained at an appropriate temperature, and the juice within the second and third-floor kitchenette and main dining room juice machines was not maintained at appropriate temperatures. Findings include: 1. Third-Floor Kitchenette Refrigerator During an observation on 9/7/21 at 6:30 PM, the state thermometer was placed in the third-floor kitchenette refrigerator, the door to the refrigerator was opened and kept open for 30 seconds. The state thermometer temperature jumped from 43 Fahrenheit (F) to 56 F. During an observation on 9/8/21 at 9:15 AM, with the Food Service Director present, there was a poured glass of milk in the third-floor…

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 interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to ensure food and drinks were palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (9/7/21 dinner and 9/8/21 lunch) reviewed. Specifically, multiple food items including pulled pork, peaches in syrup, Jello, cranberry juice, and Caesar salad were not served at palatable temperatures. Additionally, a container of coleslaw was not held at a safe temperature in a kitchenette refrigerator. Findings include: During an observation on 9/7/21 at 6:00 PM, a dinner meal tray was delivered to the resident in room C2. Temperature and taste tests were conducted on the meal tray and the resident received a replacement. At 6:03 PM the following temperatures were measured: - pulled pork 128 Fahrenheit (F); -peaches in syrup 68 F; - Jello 63 F. The pulled pork was not warm or palatable. The peaches in syrup and the Jello were not cold or palatable. During an interview on 9/7/21 at 6:15 PM, the dining room Supervisor stated that the peaches 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.