Good Shepherd Village at Endwell

In the surveyor’s words

From the most serious findings on record at Good Shepherd Village at Endwell, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Mar 21, 2024

  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. […]

• No harm, potential for more than minimal, patternF585Mar 21, 2024

  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. […]

• No harm, potential for more than minimal, patternF677Nov 10, 2021

  Based on observation, record review and interview during the recertification and abbreviated (NY 046) 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. […]

• No harm, potential for more than minimal, patternF804Nov 10, 2021

  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. […]

• No harm, potential for more than minimal, patternF812Nov 10, 2021

  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. […]