All citations for Good Shepherd Village at Endwell

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Good Shepherd Village at Endwell

Last standard health inspection on record

November 20, 2025

Showing 1 to 25 of 30 citations

  1. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 19, 2026).

  2. No harm, with potential for more than minimal harm

    Implement emergency and standby power systems.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0041, Emergency Preparedness Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 19, 2026).

  3. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home has a plan to correct it.

  4. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 5, 2024).

  5. No harm, with potential for more than minimal harm

    Install a two-hour-resistant firewall separation.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0133, Construction Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 19, 2024).

  6. No harm, with potential for more than minimal harm

    Have an enclosure around a vertical opening shaft.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0311, Smoke Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 19, 2024).

  7. No harm, with potential for more than minimal harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 5, 2024).

  8. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 19, 2024).

  9. No harm, with potential for more than minimal harm

    Ensure that testing and maintenance of electrical equipment is performed.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 19, 2024).

  10. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  11. No harm, with potential for more than minimal harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  12. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  13. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  14. No harm, with potential for more than minimal harm

    Keep all essential equipment working safely.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0908, Environmental Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  15. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 21, 2021).

  16. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 21, 2021).

  17. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 21, 2021).

  18. No harm, with potential for more than minimal harm

    Ensure that testing and maintenance of electrical equipment is performed.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 21, 2021).

  19. No harm, with potential for more than minimal harm

    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0678, Quality of Life and Care Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 19, 2026).

  20. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 19, 2026).

  21. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 19, 2026).

  22. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  23. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  24. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

  25. No harm, with potential for more than minimal harm

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of November 10, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2021).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.