Good Shepherd-Fairview Home Inc

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and interviews during the recent recertification survey conducted 7/29/2025-8/1/2025 the facility did not ensure the results of the most recent survey and the corresponding plan of correction were readily accessible to residents and their representatives, as required.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00368765), the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1's care plan documented to remove the walker from their room when not in use. Subsequently, the resident fell from bed, their neck became entangled on the basket attached to their walker, and they were found without a pulse or respirations and expired. This resulted in Immediate Jeopardy past non-compliance, to Resident #1.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.