Inspection Reports for
Good Shepherd-Fairview Home Inc
80 Fairview Avenue, Binghamton, NY, 13904
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 1, 2025
Visit Reason
The inspection was a recertification survey conducted from 7/29/2025 to 8/1/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to make survey results accessible to residents, incomplete care plans for residents on anticoagulants, diabetic, and hypertensive medications, inadequate treatment and documentation of pressure ulcers, improper medication record keeping and storage, unsafe food handling practices, and lapses in infection prevention and control practices including wound care and hand hygiene.
Deficiencies (8)
F 0577: The facility did not ensure the results of the most recent survey and plan of correction were readily accessible to residents and their representatives.
F 0656: The facility failed to develop care plans that included anticoagulant, diabetic, and antihypertensive medications for four residents reviewed.
F 0684: Resident #8's diabetes diagnosis was incorrect, sliding scale insulin orders were not updated timely, no parameters for provider notification were included, and diabetic eye exam was not scheduled.
F 0686: Resident #5 with pressure ulcers did not receive ordered protective dressing, wound was not properly staged after opening, and privacy was not maintained during wound care.
F 0755: The facility did not maintain accurate controlled substance accountability records for narcotics administered to residents.
F 0761: The facility medication cart and medication room contained expired eye drops, unlabeled medication vials, expired vaccines, and the medication cart was left unattended and unlocked.
F 0812: The 3rd floor kitchenette had staff food stored improperly, undated food items in the refrigerator, wet dishes not dried properly, and debris on the air conditioning vent.
F 0880: The facility failed to follow enhanced barrier precautions for wound care, including lack of hand hygiene, improper handling of wound supplies, and failure to wear gowns and gloves as required. Hand hygiene was also not performed consistently during medication administration.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Medication discrepancies: 4
Expired eye drops: 3
Undated dressing cups: 17
Wet juice cups: 37
Wet insulated plate domes and bottoms: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Named in findings related to medication administration, narcotic reconciliation, and medication cart security. |
| Licensed Practical Nurse #21 | Licensed Practical Nurse | Named in wound care deficiencies and failure to follow enhanced barrier precautions. |
| Director of Nursing | Provided statements regarding care plan responsibilities, medication policies, and infection control. | |
| Medical Provider #6 | Medical Doctor | Referenced in resident care and medication orders. |
| Nurse Practitioner #3 | Nurse Practitioner | Referenced in diabetic care and endocrinology recommendations. |
| Certified Nurse Aide #16 | Certified Nurse Aide | Interviewed regarding resident care knowledge. |
| Licensed Practical Nurse Unit Manager #14 | Licensed Practical Nurse Unit Manager | Interviewed regarding care plan development and medication order processing. |
| Food Service Worker #19 | Food Service Worker | Interviewed regarding food service and sanitation. |
| Food Service Director | Food Service Director | Interviewed regarding food safety and sanitation. |
| Infection Preventionist | Interviewed regarding infection control practices and education. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Aug 1, 2025
Visit Reason
Complaint Survey with 8 health and 6 life safety citations including deficiencies in care planning, food sanitation, infection control, medication labeling, pharmacy procedures, quality of care, resident rights, pressure ulcer treatment, and multiple life safety code issues.
Findings
Complaint Survey with 8 health and 6 life safety citations including deficiencies in care planning, food sanitation, infection control, medication labeling, pharmacy procedures, quality of care, resident rights, pressure ulcer treatment, and multiple life safety code issues.
Deficiencies (14)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Label/store drugs and biologicals
Pharmacy srvcs/procedures/pharmacist/records
Quality of care
Right to survey results/advocate agency info
Treatment/svcs to prevent/heal pressure ulcer
Electrical systems - essential electric syste
Ep testing requirements
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Multiple occupancies - construction type
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
Complaint Survey with a Level 4 deficiency for accident hazards and supervision indicating immediate jeopardy, corrected by December 11, 2024.
Findings
Complaint Survey with a Level 4 deficiency for accident hazards and supervision indicating immediate jeopardy, corrected by December 11, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with safety and care plan requirements following an incident involving a resident fall and subsequent death.
Findings
The facility failed to ensure the residents' environment was free from accident hazards and did not adequately update or communicate care plan interventions. This failure contributed to a resident's fall and death by strangulation due to the walker being left in the resident's room contrary to care plan instructions.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Resident #1's walker was not removed from their room as required, leading to a fatal fall and strangulation.
Report Facts
Residents Affected: 3
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #6 | Licensed Practical Nurse Manager | Named in relation to care plan updating failures and retraining |
| Certified Nurse Aide #1 | Certified Nurse Aide | Found resident with neck caught on walker basket and unaware of walker storage requirement |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Documented incident reports and provided statements about resident's condition |
| Occupational Therapist #7 | Occupational Therapist | Provided evaluation and treatment plan and statements about discontinuation of ambulation goal |
| Coroner #4 | Coroner | Conducted autopsy and provided cause of death determination |
| Director of Nursing | Director of Nursing | Provided statements about care plan review responsibilities and auditing |
| Medical Director | Medical Director | Provided statements about care plan expectations and cause of death |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Jan 19, 2024
Visit Reason
Complaint Survey with multiple Level 2 deficiencies including bedrails, food sanitation, infection control, medication labeling, and life safety code issues, all corrected by March 15, 2024.
Findings
Complaint Survey with multiple Level 2 deficiencies including bedrails, food sanitation, infection control, medication labeling, and life safety code issues, all corrected by March 15, 2024.
Deficiencies (10)
Bedrails
Food procurement,store/prepare/serve-sanitary
Infection control
Label/store drugs and biologicals
Electrical equipment - testing and maintenanc
Fire alarm system - testing and maintenance
Fire drills
Fundamentals - building system categories
Plan based on all hazards risk assessment
Subdivision of building spaces - smoke barrie
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 19, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulations regarding the use of bed rails and resident safety.
Findings
The facility failed to ensure residents were assessed for risk of entrapment from bed rails prior to installation, did not review risks and benefits with residents or their representatives, and did not obtain informed consent before installing bed rails for 5 residents. An incident occurred where a resident was found with their arm entrapped in a bed rail causing abrasions.
Deficiencies (1)
F 0700: The facility did not assess residents for entrapment risk, review risks and benefits, or obtain informed consent prior to bed rail installation for 5 residents. Resident #24 was found with their arm entrapped in the bed rail causing abrasions.
Report Facts
Residents affected: 5
Date survey completed: Jan 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #6 | Licensed Practical Nurse Supervisor | Signed restrictive device and bed rail determination forms; involved in assessment and documentation of bed rail use. |
| Registered Nurse #11 | Registered Nurse | Removed Resident #24's arm from bed rail and assessed injury. |
| Certified Nurse Aide #12 | Certified Nurse Aide | Provided care to Resident #24 and reported on assist rail use. |
| Social Worker #13 | Social Worker | Discussed Resident #24's bed rail incident and care plan in interdisciplinary team meeting. |
| Director of Social Work | Director of Social Work | Provided information on team decision-making regarding bed assist rails. |
| Director of Nursing | Director of Nursing | Provided information on bed assist rail screening, care plans, and education. |
| Director of Therapy | Director of Therapy | Provided information on bed rail determination forms and therapy recommendations. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 19, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey of the nursing home facility to assess compliance with regulatory requirements.
Findings
The facility failed to ensure residents were properly assessed and consent obtained prior to installation of bed rails, resulting in an entrapment incident. Additionally, expired and unlabeled medications were found in medication carts, and food safety standards were not met in the kitchen due to unclean surfaces and expired or undated bread products.
Deficiencies (3)
F 0700: The facility did not ensure residents were assessed for risk of entrapment from bed rails, risks and benefits reviewed, or informed consent obtained prior to installation for 5 residents. Resident #24 was found with arm entrapped causing abrasions.
F 0761: The facility did not ensure drugs and biologicals were stored and labeled according to professional standards. Medication cart contained expired aspirin, unlabeled insulin pens, and insulin pens opened beyond 28 days.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Main kitchen dish machine area walls were unclean, ceiling tile grid was rusty, and expired and undated bread products were found.
Report Facts
Residents affected: 5
Expired aspirin bottles: 1
Aspirin bottles without expiration date: 2
Unlabeled insulin pens: 1
Insulin pens opened beyond 28 days: 1
Expired bread best by date: 1
Undated bread items: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #6 | Licensed Practical Nurse Supervisor | Signed bed rail determination and restrictive device forms; noted missing informed consent sections |
| Registered Nurse #11 | Registered Nurse | Removed Resident #24's arm from bed rail entrapment and assessed injury |
| Certified Nurse Aide #12 | Certified Nurse Aide | Provided care to Resident #24 and described assist rail use |
| Social Worker #13 | Social Worker | Discussed Resident #24's bed rail incident and care plan |
| Director of Social Work | Director of Social Work | Discussed team decision process for bed assist rails and knowledge gaps on informed consent |
| Director of Nursing | Director of Nursing | Described bed rail screening and interdisciplinary team process; noted lack of informed consent |
| Director of Therapy | Director of Therapy | Provided therapy assessment notes and rationale for bed assist rails use |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed expired and unlabeled medications in medication cart |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Described medication cart stocking and labeling responsibilities |
| Licensed Practical Nurse Supervisor #6 | Licensed Practical Nurse Supervisor | Described medication checking expectations and lack of auditing tools |
| Director of Nursing #7 | Director of Nursing | Confirmed lack of auditing tool for medication storage and labeling |
| Food Service Director | Food Service Director | Reported on kitchen cleaning responsibilities and food labeling issues |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
Complaint Survey with a Level 2 deficiency for investigating and preventing alleged violations, corrected by August 4, 2023.
Findings
Complaint Survey with a Level 2 deficiency for investigating and preventing alleged violations, corrected by August 4, 2023.
Deficiencies (1)
Investigate/prevent/correct alleged violation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The abbreviated survey was conducted to investigate an allegation of resident abuse involving inappropriate touching by a certified nurse aide (CNA) reported by Resident #1.
Complaint Details
The complaint involved an allegation of sexual abuse by CNA #1 against Resident #1. The allegation was reported on 7/9/2023. The facility conducted interviews, assessments, and a full investigation but was unable to substantiate the abuse. The resident was monitored and staff were educated on abuse policies.
Findings
The facility did not ensure residents were protected from potential abuse while an investigation was in progress. Resident #1 reported inappropriate touching by CNA #1, who was not immediately removed from resident access. The facility was unable to substantiate the allegation after investigation and provided education to staff on abuse policies.
Deficiencies (1)
F 0610: The facility failed to protect residents from potential abuse by not immediately removing CNA #1 from resident access during an investigation of alleged inappropriate touching reported by Resident #1.
Report Facts
Date of survey completion: Jul 24, 2023
Dates CNA #1 worked: 3
Date allegation reported: Jul 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNS/House Charge #3 | Reported allegation to DON, conducted resident assessment, and participated in investigation | |
| Director of Nursing (DON) | Notified of allegation, initiated full investigation, and suspended CNA #1 | |
| Administrator | Notified of allegation and completed investigation summary | |
| Certified Nurse Aide (CNA) #1 | Accused staff member in abuse allegation, suspended during investigation | |
| Certified Nurse Aide (CNA) #2 | Received initial report from resident and reported to supervisor |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 28, 2023
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 14, 2022
Visit Reason
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Findings
Covid-19 Survey with a Level 2 deficiency for reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 9, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal, state, and local regulations for the nursing home.
Findings
The facility failed to ensure food and drinks were served at safe and palatable temperatures, did not notify the New York State Department of Health of a loss of service for the dish machine, and failed to maintain essential equipment including a kitchenette refrigerator and juice machines at appropriate temperatures.
Deficiencies (3)
F 0804: The facility failed to ensure food and drinks were palatable, attractive, and served at safe temperatures during 2 meals. Multiple food items and a container of coleslaw were not held at appropriate temperatures.
F 0836: The facility failed to notify the New York State Department of Health of a loss of service for the commercial dish machine lasting more than four hours, violating incident reporting requirements.
F 0908: The facility failed to maintain safe operating conditions for 1 kitchenette refrigerator and 3 juice machines. Temperatures exceeded acceptable ranges, risking food safety.
Report Facts
Food temperatures: 128
Food temperatures: 68
Food temperatures: 63
Food temperatures: 51
Food temperatures: 50
Food temperatures: 49
Food temperatures: 51
Refrigerator temperature: 56
Milk temperature: 47
Juice temperatures: 51
Juice temperatures: 50
Juice temperatures: 48
Juice temperatures: 46
Viewing
Loading inspection reports...
