Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Shepherd-fairview Home Inc during CMS and state inspections, most recent first.
Missing medication-related care plans: The facility did not include key treatment needs in care plans for 4 of 4 residents reviewed. A resident on Eliquis had no anticoagulation care plan despite cardiac history and reported nosebleeds, another resident on Apixaban lacked anticoagulation documentation, and a resident receiving antihypertensive meds had no HTN care plan. Staff and the DON stated these medication-related care plans should have been present.
An LPN failed to follow EBP during wound care for a resident with chronic wounds, placing supplies on unclean surfaces, using unclean scissors on multi-use dressing material, and not changing gloves or performing hand hygiene between dirty and clean tasks. The LPN also did not wear the required PPE for the resident’s EBP. In addition, an LPN administered meds to multiple residents without hand hygiene between residents.
A resident with Type 1 DM had inaccurate EMR/MDS coding, no documented diabetes care plan, and insulin sliding scale orders that were not updated with clear provider-notification parameters. Staff were unaware of a low blood sugar event and the resident’s recommended diabetic eye exam was neither scheduled nor documented as completed. Interviews confirmed the resident should have had a diabetic/insulin care plan and that sliding scale orders should include call parameters.
Pressure ulcer care was not provided as ordered for a resident with PVD, dementia, and impaired mobility. The resident’s right heel wound was followed as a DTI even after it opened and changed in appearance, and the ordered protective dressing for the right palm was not in place during observations. The resident’s privacy was also not maintained during wound care.
Controlled substance accountability records were not accurately reconciled for four residents after an LPN administered narcotic doses from a rehab unit cart. The LPN documented the doses in the MAR but had not signed them out in the narcotic reconciliation book at the time they were given, and the DON stated narcotic and controlled meds should be signed out when administered because failure to do so raises a concern for diversion.
Unlabeled, expired medications and biologicals were found in the Rehab Unit medication cart and medication room, including opened eye drops past their use period, unlabeled resident-specific lidocaine vials mixed with house stock, expired flu vaccine, and expired treatment cream. The DON and LPN stated some items should have been disposed of, and an LPN also left the medication cart open, unattended, and out of sight while retrieving a ginger ale.
Kitchenette Food Storage and Sanitation Deficiencies: In one kitchenette, an opened energy drink was stored in the resident refrigerator, 17 dressing cups were undated, and multiple cups plus insulated plate domes and bottoms were stacked wet after washing. Debris was also observed on the AC vent near the steam table. The FSW stated they did not check that dishes were dry, and the FSD stated staff should not store personal items in resident refrigerators and that items were expected to be dated.
Survey results and the corresponding POC were not readily accessible to residents and families. Residents in council were unaware of where to find the most recent CMS-2567, the lobby had no visible notice about survey information, and the survey binder was found hidden on a shelf under a plant with unrelated papers on top. The receptionist knew where the folder was but did not know it had to be readily accessible, and the Administrator stated the binder should have been placed where residents could access it.
A resident with dementia and impaired cognition was found deceased after becoming entangled in a walker's basket, which was supposed to be stored at the nursing station when not in use. The care plan was not updated to reflect the resident's non-ambulatory status, and the walker was left in the room, leading to the fatal incident. Staff were unaware of the requirement to remove the walker due to discrepancies between the care plan and the Kardex.
Missing Medication-Related Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed residents’ medical needs and medication-related care for 4 of 4 residents reviewed. The deficiency involved Resident #65, Resident #4, Resident #8, and Resident #5, whose care plans did not include key treatment areas identified in their records, including anticoagulant therapy for Residents #65 and #4, diabetic medications for Resident #8, and antihypertensive medications for Resident #5. The facility policy stated that interdisciplinary team members were responsible for initiating and updating care plan problems, goals, and approaches, and that the care manager would gather input and enter the information into the care plan. Resident #65 had diagnoses including atrial fibrillation and coronary artery disease, and physician orders included Eliquis 5 mg twice daily. The admission history and physical stated the resident had a significant cardiac history and was to continue cardiac medications including aspirin and Eliquis. The comprehensive care plan addressed fall risk and education on fall risks, but it did not include anticoagulant use. The care card also lacked documentation related to anticoagulant medication. During observation and interview, Resident #65 stated they had spontaneous nosebleeds from being on a blood thinner, and staff interviews confirmed they were not aware of a blood thinner-related care plan. Resident #4 had diagnoses including anemia, hypertension, atrial fibrillation, and a left hip fracture, and the record showed anticoagulant therapy with Apixaban 2.5 mg twice daily. The care plan identified fall risk and lack of awareness of safety needs, but did not document anticoagulant therapy. Resident #5 had diagnoses including hypertension, peripheral vascular disease, and dementia with behavioral disturbance, and physician orders included Amlodipine Besylate 2.5 mg daily and irbesartan 150 mg daily with a hold parameter for low systolic blood pressure. The resident received the medications as ordered, but there was no documented care plan for hypertension or antihypertensive medications. Staff interviews stated residents on anticoagulants or antihypertensives should have care plans addressing monitoring and related symptoms, and the DON stated care plans should be updated for medication changes and treatment needs.
Infection Control Failures During Wound Care and Medication Pass
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program for one resident reviewed. Resident #5 had diagnoses including peripheral vascular disease and hypertension, and the 5/25/2025 MDS documented severely impaired cognition, one unstageable pressure injury, and one venous or arterial ulcer. The care plan documented a left second toe peripheral vascular wound that opened on 1/26/2025, a deep tissue injury to the right posterior heel that occurred on 1/27/2025, and enhanced barrier precautions related to a chronic wound. Physician orders directed daily wound care for the left second toe and right posterior heel, and a 7/29/2025 order documented the resident was on enhanced barrier precautions for chronic wounds. During wound care observation, an LPN wrote the wound care order on a sticky note, gathered supplies from the treatment cart without hand hygiene or gloving, and carried the supplies to the resident’s room with an ungloved hand. The supplies were placed on an unprotected treatment cart surface, then on an uncleaned nightstand, with unpackaged gauze touching the nightstand and scissors placed on the sticky note. The nurse washed hands in the bathroom, then performed wound care while the resident sat in a wheelchair. After putting on gloves, the nurse moved supplies around the room, placed paper towels on the floor under the resident’s heel, and continued wound care without changing gloves or sanitizing hands after removing the dirty dressing. Unwrapped gauze was sprayed with wound wash and held against the wound, multi-use Adaptic was cut with uncleaned scissors, and additional supplies were placed on the floor next to the dirty dressing. The nurse applied the dressing, heel protector, and gauze wrap, cut the gauze with uncleaned scissors, replaced the resident’s sock and slipper, and then treated the left second toe without changing gloves or performing hand hygiene. The nurse removed gloves only after discarding supplies, placed the uncleaned scissors in a uniform pocket, and returned the wound wash and Adaptic package to the treatment cart before washing hands in the common area. The observation also showed that enhanced barrier precautions were not followed during the wound care. The nurse did not wear the required PPE for the resident’s enhanced barrier precautions at any point during the treatment. In interview, the nurse stated they forgot the resident was on enhanced barrier precautions and acknowledged that wound care items should not be placed on unclean surfaces, gloves should have been changed, and hand hygiene should have been performed at key points during the procedure. The unit manager and infection preventionist stated that gowns and gloves should be worn for wound care on a resident with enhanced barrier precautions, supplies should not be placed on unclean or floor surfaces, scissors should not be used uncleaned on multi-use dressings, and hand hygiene and glove changes should occur between dirty and clean tasks. During medication administration observation, an LPN administered medications to five residents without performing hand hygiene between residents. The nurse stated they did not remember to wash their hands between residents and often got into a rush and forgot. The infection preventionist stated hand hygiene should be performed during medication administration and that LPNs should at least use gloves for each administration and hand sanitizer between each resident.
Diabetes Care Plan, Insulin Orders, and Eye Exam Not Managed
Penalty
Summary
Resident #8’s diabetes-related care was not managed in accordance with the resident’s orders, preferences, and goals. The resident’s electronic medical record listed Type 2 diabetes mellitus with hyperglycemia and diabetic neuropathy, and the MDS dated 7/10/2025 coded the resident as having Type 2 diabetes mellitus and receiving daily insulin with changes. However, the endocrinology note dated 4/17/2025 documented that the resident had been diagnosed with Type 1 diabetes following pancreatitis in 2006, and the physician progress note dated 6/18/2025 also documented Type 1 Diabetes Mellitus. Staff interviews confirmed the resident was a Type 1 diabetic and should have had a diabetic/insulin care plan, but no diabetes mellitus plan of care was documented. The resident’s insulin management was also not updated timely. A physician order dated 5/28/2025 for Humalog sliding scale at 7:00 AM was later discontinued, and the unit manager stated the resident had a blood sugar of 72 on 7/21/2025, which they were unaware of. The unit manager also stated the resident did not have an order to notify the provider when blood sugar reached a certain level and that notification was based on clinical judgment. The medical provider stated sliding scale insulin orders were supposed to include parameters for when nursing staff were to call the physician, and they were unaware the resident had four sliding scales without such parameters. The resident also did not have the recommended diabetic eye exam scheduled. The endocrinology note and after-visit summary documented a recommendation for an updated yearly diabetic eye exam and requested the facility assist with scheduling, but there was no documented evidence that the exam was completed or scheduled. The unit secretary stated they had not scheduled the eye exam and were unaware of the endocrinologist’s recommendation. The facility policy required nurses to follow sliding scale orders and notify the RN, NP, and physician as indicated, and required comprehensive care plans to be completed and updated for resident needs.
Pressure Ulcer Care and Privacy Not Maintained
Penalty
Summary
Resident #5 did not receive necessary pressure ulcer care consistent with professional standards of practice. The resident had diagnoses including peripheral vascular disease, dementia with other behavioral disturbance, and hypertension. The 5/25/2025 MDS documented the resident was severely cognitively impaired, had impairment to both upper and lower extremities, was at risk for pressure ulcers, and had one unstageable pressure injury that presented as a deep tissue injury. The care plan documented potential for skin breakdown related to hypertension, impaired cognition, and impaired mobility, and included a right palm protective dressing order for preventative care. The right posterior heel wound was followed as a deep tissue injury, but once the wound opened it was not reclassified to the appropriate stage. Wound documentation showed changes in size and tissue appearance over time, including measurements of 0.5 cm by 1 cm with odor and no drainage, then 0.9 cm by 1.2 cm by 0.1 cm with scant serous drainage and 50% red tissue and 50% tendon, and later 0.7 cm by 1 cm by 0.1 cm with scant serous drainage and 80% glistening white tendon. During observations, the resident did not have the ordered small Allevyn Ag Gentle Border Adhesive dressing applied to the right palm as ordered for preventative care, and the resident's privacy was not maintained during wound care.
Controlled substance records were not reconciled for four administered narcotic doses
Penalty
Summary
The facility did not maintain an accurate system of records and accounts for controlled drugs on one of two nursing carts reviewed in the Rehab Unit. During the recertification survey, the controlled substance accountability record was found not to match the medications that had been administered to four residents. The facility policy required controlled substances to be handled, stored, disposed of, and recorded according to applicable laws and regulations, and required reconciliation of narcotic and controlled medications during the shift or at change of shift. It also required the licensed individual administering the medication to record the administration in the MAR at the time the medication was given and to initial and date the blister pack for the dose administered. During observation and interview, an LPN administered four narcotic medications to four residents but had not signed them out in the narcotic reconciliation book. One resident received oxycodone 10 mg with 9 pills remaining in the blister pack while the accountability record showed 10; another resident received oxycodone 5 mg with 10 pills remaining while the record showed 11; a third resident received tramadol/APAP 37.5-325 mg with 2 pills remaining while the record showed 3; and a fourth resident received Percocet with 13 pills remaining while the record showed 14. The LPN stated the medications had been given that morning and acknowledged they had not been signed out in the narcotic reconciliation book because they were very behind. The DON stated narcotic and controlled medications should be signed out at the time they are given and that failure to do so raises a concern for diversion of controlled substances.
Unlabeled, Expired Medications and Unsecured Medication Cart
Penalty
Summary
Drugs and biologicals in the Rehab Unit were not labeled and stored in accordance with accepted professional principles. During observation of the Rehab Unit medication cart, three multidose eye drop bottles were found opened and expired: two bottles of latanoprost 0.005% opened on 6/14/2025 and one bottle of dorzolamide solution 2% opened on 6/14/2025. The LPN stated the eye drops were good for 30 days after opening, but also stated they did not usually look at the open dates and were usually in a hurry. The DON stated eye drops opened on 6/14/2025 should not have been given because they were beyond the manufacturer’s recommended use period. In the Rehab Unit medication room, two opened vials of Lidocaine Hydrochloride 1% injection were mixed into house stock and were not labeled with a resident name, a box of medications and cold packs to be destroyed was stored under the sink, and the medication fridge contained influenza vaccines and refrigerated medication bags sitting in water, including an unopened box of high-dose influenza vaccine that had expired. A tube of Secura Protective Cream in the treatment cart was also expired. In addition, the Rehab Unit medication cart was observed left open, unattended, and out of sight of the LPN while the LPN went down the hallway to retrieve a ginger ale; the LPN stated the cart should have been locked but they were busy and forgot.
Kitchenette Food Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in one of two kitchenette areas. During observation of the 3rd floor kitchenette, an opened 16-ounce energy drink was found in the refrigerator, along with 17 individual 2-ounce dressing cups with lids that were undated. In the cupboard, 37 various 4-ounce and 6-ounce juice cups were stacked while wet, and there was a wet spot on the shelf where the cups had been placed. Also observed were 27 insulated plate domes and bottoms stacked wet, and debris on the air conditioning vent near the steam table. During interview, the Food Service Worker stated they did not check to make sure the cups were dry after washing them, and the Food Service Director stated maintenance should have been cleaning the air vents monthly to prevent potential physical contamination of food items while food was being served. The Food Service Director also stated the resident refrigerators in the kitchenettes were for resident items only and that staff should not store personal items there because staff had their own breakroom. In a later interview, the Food Service Director stated they did not date items on the production sheet and expected items to be dated.
Survey Results Not Readily Accessible
Penalty
Summary
The facility did not ensure that the results of the most recent survey and the corresponding plan of correction were readily accessible to residents and their representatives. During a Resident Council meeting, residents in attendance were unaware of the location of a copy of the most recent Statement of Deficiencies (Form CMS-2567) or the Plan of Correction. An observation in the main lobby found no visible information indicating the detailed availability of past survey information, and the survey binder was located on top of a shelf under a plant with random unrelated papers placed on top. The folder contained the results of complaint surveys from 2024. During interviews, the front desk Receptionist stated they knew the location of the folder but were not aware the results were required to be readily accessible to all residents and families. The Administrator stated they were responsible for the placement of the survey results and that the binder should have been placed where residents could access it.
Failure to Remove Walker Leads to Resident's Death
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fatal incident. The resident, who had diagnoses including dementia and severely impaired cognition, was care planned to have their walker stored at the nursing station when not in use. However, the walker was left in the resident's room, and the resident was found entangled in the walker's basket after falling from bed, resulting in their death. The care plan was not updated to reflect the resident's non-ambulatory status, and the walker was not removed from the room as required. The facility's policies on accident prevention and care plan updating were not followed. The resident's care plan documented the need for the walker to be stored away, but this intervention was not transferred to the Kardex, which staff used for immediate care instructions. The Kardex did not reflect the resident's current status or the necessary interventions, leading to staff being unaware of the requirement to remove the walker. The resident's environment was not managed to be free of hazards, contributing to the incident. Interviews with staff revealed a lack of communication and process for updating care plans and Kardexes. The Licensed Practical Nurse Manager responsible for updating care plans did not ensure the interventions were transferred to the Kardex, and there was no system alert for failed transfers. The Occupational Therapist discontinued the resident's ambulation goal but did not ensure the walker was removed from the room. The Director of Nursing and other staff were unaware of the discrepancies between the care plan and the Kardex, which ultimately led to the resident's death by strangulation.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Binghamton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgewater Center For Rehab & Nursing L L C | 0.5 mi | ★★★★★ | 0 | 0 |
| Elizabeth Church Manor Nursing Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Susquehanna Nursing & Rehabilitation Center, L L C | 4.3 mi | ★★★★★ | 1 | 0 |
| James G Johnston Memorial Nursing Home | 4.8 mi | — | 0 | 0 |
| Willow Point Rehabilitation And Nursing Center | 4.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.