Good Shepherd Village at Endwell

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview during the recertification survey conducted 3/18/2024-3/21/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 Federal Health Recertification survey (11/10/2021). Specifically, the results of the most recent Federal health recertification survey conducted 11/10/2021 were in the temporary main entrance to the Assisted Living residence and were not accessible to all residents without having to ask for assistance.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.