Good Shepherd Village At Endwell

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey conducted 11/19/2025-11/20/2025, the facility did not verify the presence of advance directives or the resident's wishes regarding cardio-pulmonary resuscitation, upon readmission, for one (1) of three (3) residents (Resident #21) reviewed. Specifically, during a hospitalization Resident #21 changed their advance directives to include cardio-pulmonary resuscitation should they be found without a pulse, their readmission orders did not reflect their preference and there was a do not resuscitate (allow natural death) order in place for two (2) days after readmission. Findings include: The undated facility policy EMOLST (Electronic Medical Orders for Life-Sustaining Treatment)/Advanced Directives, retrieved 11/2025, documented residents had the right to direct their own medical treatment, including withholding or withdrawing life sustaining treatment and their wishes were documented in their electronic medical record. Hospital advance…

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 and interview during the recertification survey conducted 3/18/2024 - 3/21/2024, 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 communicable diseases and infections. Specifically, the facility's infection prevention control plan was not reviewed annually and did not include water management as required. Findings include: The facility policy Infection Prevention and Control Program dated 2018, documented the Infection Prevention and Control Committee, Medical Director, Director of Nursing Services, and other key clinical administrative staff review the infection control policies at least annually. The review would include updating or supplementing policies and procedures as needed. There was no documented evidence the facility's Infection Prevention and Control Program plan included water management and measures to prevent the growth of Legionella (a bacteria that causes Legionnaire's disease) 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.

Based on record review and interviews during the recertification survey conducted 3/18/2024-3/21/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 6 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Findings include: The facility policy, Grievances, Concerns and Suggestions revised 7/29/2019 documented all the residents would have a right to voice grievances without fear of reprisal. The social worker was responsible to present and explain to the resident/family/designated representative information pertinent to a resident's grievance rights upon admission. The policy did not include education provided to the resident on how to file a grievance. The facility's Grievance, Concerns, and Suggestion Tracking Logs dated 7/1/2023 to 12/31/2023 and 1/1/2024 to 6/30/2024 documented there were no grievances for these time periods. During a Resident Council Meeting on 3/18/2024 at 2:07 PM, six anonymous residents…

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 and interview during the recertification and abbreviated (NY00285046) surveys conducted from 11/8/21-11/10/21, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 3 residents (Residents #3 ,4, and 34) reviewed. Specifically, Resident #3 did not receive incontinence care and was not shaved as planned, Resident #4 did not receive timely meal assistance, and Resident #34 did not receive nail care as planned. Findings include: The facility's undated certified nursing assistant (CNA) competency skill check list included feeding (enhancing the dining experience), incontinence care, and hygiene (nail and skin care). The facility policy Urinary Incontinence - Toileting Needs revised 6/28/18 documented any resident who is incontinent of bladder will receive appropriate treatment and services. 1) Resident #3 had diagnoses including…

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 from 11/8/21-11/10/21, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meal trays tested (breakfast, lunch, dinner). Specifically, food was not served at palatable and safe temperatures for the 11/8/21 dinner meal and the 11/9/21 breakfast meal. The 11/8/21 dinner meal and the 11/9/21 lunch meal were not palatable or appetizing. Findings include: The facility's mealtimes were documented as 8 AM for breakfast, 12:30 PM for lunch, and 6 PM for dinner. The facility policy Sanitary Conditions revised 2/22/16, documented all perishable foods must be 45 degrees Fahrenheit (F) or below. Hot foods should be held at 140 degrees F or above. During a resident meeting on 11/8/21 at 1:58 PM, 3 anonymous residents reported the food was often cold and the meat was often tough to chew. During the dinner meal observation on 11/8/21 at 6:07 PM, the BBQ chicken breast was measured at 131 degrees F and the macaroni salad 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 observation and interview during the recertification survey conducted from 11/8/21-11/10/21 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, there were undated and unlabeled foods, unclean areas and dented cans observed in the main kitchen. Findings include: The facility dining services policy Sanitary Conditions dated 2/22/2016 documents food is stored in such a manner as to be protected against contamination. Storage areas must be kept dry and clean from debris. Plastic containers with tight-fitting lids or resealable plastic bags should be used to store dry items that have been opened. All products that have been previously opened should be labeled and dated. The facility dining services policy Equipment and Utensil Cleaning and Sanitization dated 2/17/16 did not include the procedure for cleaning food service equipment other than dishware, pots, pans, and utensils. The following was observed during a kitchen tour on 11/8/21: - at 10:16 AM…

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 and interview during the recertification survey 11/8/21 - 11/10/21 the facility did not 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 communicable diseases and infections including COVID-19 for 1 of 1 resident (Resident #83) reviewed for pressure ulcers, 1 of 2 residents (Resident #183) reviewed for transmission based precautions and 3 observed staff (certified nurse aide, CNA #4, registered nurse (RN) Unit Manager #6 and the Director of Nursing, DON). Specifically, licensed practical nurse (LPN) #1 did not perform appropriate hand hygiene and did not keep clean supplies separate from dirty supplies during a wound dressing for Resident #83; CNA #15 was observed not wearing appropriate PPE (personal protective equipment) when entering the room of Resident #183 who was on isolation/transmission-based precautions for potential COVID-19 exposure; and CNA…

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 11/8/21-11/10/21 the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 3 dishwashers (main kitchen dishwasher, short hall and long hall dining room dishwashers). Specifically, the main kitchen dishwasher had a component that was not working, the short hall dining room dishwasher was not working, and there was water underneath and around the long hall dining room dishwasher. Findings include: During an interview on 11/8/21 at 9:45 AM, health care server #14 stated the short hall dining room dishwasher had been broken for 2 months. They stated that kitchen staff would have to bring dishes down the stairs to the main kitchen, and sometimes to the memory care unit long hall dining room to wash dishes. There was no out of order sign observed on the dishwasher in the short hall dining room. During an observation on 11/8/21 at 9:50 AM the long hall dining room dishwasher was leaking. There were towels on the floor underneath 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey conducted 11/8/21-11/10/21, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident #83) reviewed. Specifically, Resident #83's wound dressing was not changed as ordered. Findings include: The facility policy Clean Wound Dressing revised 7/9/19 documents it is the policy of the facility that clean wound dressings will be applied and changed as per medical provider's orders by a licensed nurse. Resident #83 was admitted to the facility with diagnoses including malignant neoplasm (cancer) of specified parts of peritoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen), Type 2 diabetes, and right hip replacement. The 10/11/21 Minimum Data Set (MDS) assessment documented the resident 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.

Based on observation, record review and interview during the recertification survey conducted from 11/8/21-11/10/21, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents reviewed (Resident #26). Specifically, Resident #26's blood pressure medication was administered, and the resident's blood pressure and heart rate were not obtained prior to administration per physician ordered parameters. Findings include: The facility policy Medication Administration - General Guidelines revised 7/17/18 documents medications are administered in accordance with orders from the medical provider. Resident #26 had diagnoses including end stage renal (kidney) disease, atrial fibrillation (abnormal heartbeat) and congestive heart failure. The 8/26/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required supervision with setup or one-person physical assist with most activities of daily living (ADL) and was receiving dialysis treatment. A physician order dated 6/4/21 documented metoprolol tartrate (blood…

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, and record review during the recertification survey conducted [DATE]-[DATE], the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication cart (short hall medication cart) reviewed. Specifically, the medication cart for the short hall contained 2 insulin pens that were not labeled with the date they had been opened. Findings include: The facility policy Insulin Injection Administration revised [DATE] documents the procedure includes: obtain insulin pen from refrigerator and allow warming to room temperature. Label with resident identifiers, date opened, and expiration date. If using an insulin pen, follow manufacturer instructions. The undated facility policy Medication Storage documents medications are stored safely, securely, and properly, following manufacturers' recommendations or those of 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 record review during the recertification survey conducted 11/8/21- 11/10/21, the facility failed to ensure the resident menus were followed for 1 of 5 meals observed. Specifically, on 11/9/21 the approved, preplanned, and posted menu documented boiled potatoes were to be served at the lunch meal. 10 residents on the short hall were served mashed potatoes which was not an approved menu substitution, was not updated on the posted menu, and residents were not notified of the change. Finding included: The facility's 1/7/21, Week 4 Day 3 Menu documented the boiled potatoes were to be served with the lunch meal. The facility policy Menu Item Substitution dated 1/2016, documents appropriate menu substitutions will be made in the event pre-planned menu items are unavailable. The food production employee will notify the general manager or clinical designee of unavailable menu items. The clinical staff will approve menu substitutes. Notice of menu substitution will be posted adjacent to the menu on all resident units. Menu substitution will be tracked on…

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.