Inspection Reports for
Good Shepherd Village at Endwell
14 Village Drive, Endwell, NY, 13760
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Renewal
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for continued participation in Medicare and Medicaid programs.
Findings
The facility failed to verify and update the resident's advance directives and resuscitation orders upon readmission, resulting in a delay of two days before the correct physician order for cardio-pulmonary resuscitation was entered into the medical record.
Deficiencies (1)
F 0678: The facility did not verify the presence of advance directives or the resident's wishes regarding cardio-pulmonary resuscitation upon readmission for one of three residents reviewed. The resident's readmission orders did not reflect their updated preference for resuscitation for two days after readmission.
Report Facts
Residents affected: 3
Residents affected: 1
Days delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #5 | Physician | Reviewed and signed Medical Orders for Life-Sustaining Treatment; involved in resident admission and order updates |
| Nurse Practitioner #4 | Nurse Practitioner | Documented resident's condition and hospitalization |
| Licensed Practical Nurse Manager #3 | Licensed Practical Nurse Manager | Described admission/readmission paperwork process and order entry |
| Director of Nursing | Director of Nursing | Entered physician order into medical record and provided statements about order entry process |
| Administrator | Administrator | Provided expectations for timely review and entry of admission orders |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a Federal health recertification survey to assess compliance with regulatory requirements and resident rights at Good Shepherd Village at Endwell.
Findings
The facility failed to ensure that the results of the most recent Federal/State survey were posted in a place readily accessible to residents without staff assistance. The grievance process was inadequate as residents were not educated on how to file grievances and no grievances had been formally recorded. The infection prevention and control program was not reviewed annually and lacked required water management policies.
Deficiencies (3)
F 0577: The facility did not ensure the most recent Federal health recertification survey results were posted in a location accessible to all residents without staff assistance.
F 0585: The facility did not have a process to ensure residents were educated on how to file grievances, and residents were unaware of the grievance process.
F 0880: The facility failed to establish and maintain an infection prevention and control program that included annual review and water management as required.
Report Facts
Residents affected: 6
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 10, 2021
Visit Reason
The survey was a recertification and abbreviated survey conducted from 11/8/21 to 11/10/21 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to provide adequate care in activities of daily living for some residents, ensure proper pressure ulcer care, prevent medication errors, maintain food safety and palatability, follow infection control protocols including mask wearing, and maintain safe and functional equipment including dishwashers.
Deficiencies (9)
F 0677: The facility failed to provide necessary ADL care including incontinence care, shaving, timely meal assistance, and nail care for 3 residents.
F 0686: The facility failed to ensure a resident's pressure ulcer dressing was changed as ordered, missing treatment on 11/8/21.
F 0760: The facility failed to prevent a significant medication error by administering blood pressure medication without obtaining required vital signs.
F 0761: The facility failed to label insulin pens with the date opened, risking use of expired medication.
F 0803: The facility failed to follow the approved menu and notify residents of substitutions when mashed potatoes were served instead of boiled potatoes.
F 0804: The facility failed to serve food at safe and palatable temperatures for multiple meals, including overcooked meat and improperly chilled items.
F 0812: The facility failed to store, prepare, and serve food in accordance with professional standards, including unlabeled and undated foods, unclean areas, and dented cans in the kitchen.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper PPE use by staff, inadequate hand hygiene during wound care, and improper mask wearing.
F 0908: The facility failed to maintain all dishwashers in safe operating condition, with broken or leaking dishwashers and delayed reporting and repair.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Meals observed: 5
Dishwashers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and wound care deficiencies |
| CNA #4 | Certified Nurse Aide | Named in ADL care and infection control deficiencies |
| RN Unit Manager #6 | Registered Nurse Unit Manager | Named in ADL care, medication, infection control, and mask wearing deficiencies |
| Director of Nursing | Director of Nursing | Named in ADL care, infection control, and mask wearing deficiencies |
| CNA #15 | Certified Nurse Aide | Named in infection control deficiency for PPE use |
| LPN #3 | Licensed Practical Nurse | Named in ADL care deficiencies |
| Health Care Dining Manager | Named in food service and menu substitution deficiencies | |
| Operations Manager | Named in food service and dishwasher deficiencies | |
| Dining Operations Manager | Named in dishwasher deficiencies | |
| Maintenance Director | Named in dishwasher deficiencies | |
| RN Infection Preventionist #8 | Registered Nurse Infection Preventionist | Named in wound care and infection control deficiencies |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Inspection Report
Visit Reason
Inspection history and enforcement summary for Good Shepherd Village at Endwell
Findings
No citations or deficiencies reported from inspections between October 1, 2021 and September 30, 2025; one enforcement action in 2021 related to Quality of Care with a stipulation and fine.
Deficiencies (1)
Quality of Care — enforcement stipulation and fine
Report Facts
Total inspections: 0
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