Endwell, NY

Good Shepherd Village At Endwell

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

14 Village Drive, Endwell, NY

(607) 757-3102

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

32

Certified beds

Average residents

27

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2010-05-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.89

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.49

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.79

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.16

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

2.38

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

5.00

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.86

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.48

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.89

CMS adjusted RN staffing hours

Adjusted total hours

5.14

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

1,003

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

61.15

Composite VBP score used to determine payment impact.

Payment multiplier

1.0162

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

7.42

Baseline 34.21% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0.44

Adjusted total nurse staffing

4.81

Baseline 4.74 hours · Performance 4.45 hours · Measure score 4.81 · Achievement 4.81 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.54%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 6.04%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.75	1.02 0.3 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	3.25%	8.2% 4.9 pts worse	Numerator 4 · Denominator 123
Staff flu vaccination coverage	54.75%	42% 12.8 pts better	Numerator 121 · Denominator 221
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	1.7 0.4 pts worse	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.3 0.9 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	91.0%	91.2% 0.2 pts worse	93.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 87.1% · Q3 92.3% · Q4 95.7% · 4Q avg 91.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.8%	95.3% 1.5 pts worse	95.5% 1.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of long-stay residents experiencing one or more falls with major injury	11.7%	3.0% 8.7 pts worse	3.3% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.9% · Q3 11.5% · Q4 4.3% · 4Q avg 11.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.5%	18.5% 13 pts better	11.4% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 6.9% · Q3 0.0% · Q4 0.0% · 4Q avg 5.5%
Percentage of long-stay residents who lose too much weight	13.1%	6.1% 7 pts worse	5.4% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 10.7% · Q3 4.2% · Q4 15.0% · 4Q avg 13.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.4%	13.5% 9.9 pts worse	19.6% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 22.6% · Q3 24.0% · Q4 22.7% · 4Q avg 23.4%
Percentage of long-stay residents who received an antipsychotic medication	17.2%	14.8% 2.4 pts worse	16.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.4% · Q3 20.0% · 4Q avg 17.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	27.7%	15.1% 12.6 pts worse	16.3% 11.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 27.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.8%	15.5% 7.3 pts worse	14.9% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 23.1% · Q3 19.0% · 4Q avg 22.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.6% 0.6 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.5%	1.4% 5.1 pts worse	1.7% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.7% · Q3 4.0% · Q4 9.5% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	34.8%	20.8% 14 pts worse	19.8% 15 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 30.7% · Q3 39.8% · Q4 15.6% · 4Q avg 34.8%
Percentage of long-stay residents with pressure ulcers	5.4%	6.9% 1.5 pts better	5.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.1% · Q3 7.1% · Q4 3.6% · 4Q avg 5.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	62.3%	76.7% 14.4 pts worse	81.7% 19.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q4 75.0% · 4Q avg 62.3%
Percentage of short-stay residents who had an outpatient emergency department visit	8.2%	9.7% 1.5 pts better	12.0% 3.8 pts better	Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 8.3% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.9%	20.6% 4.3 pts worse	23.9% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 25.0% · Expected 24.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-20 · Fire 2025-11-20

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2024-03-21 · Fire 2024-03-21

3 health deficiencies

Top issue: Resident Rights (2 deficiencies)

5 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2021-11-10 · Fire 2021-11-10

9 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-11-20

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2026-01-19

F · Potential for more than minimal harm 2025-11-20

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2026-01-19

F · Potential for more than minimal harm 2025-11-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2026-01-19

D · Potential for more than minimal harm 2025-11-20

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2026-01-19

D · Potential for more than minimal harm 2025-11-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-01-19

F · Potential for more than minimal harm 2024-03-21

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2024-05-19

F · Potential for more than minimal harm 2024-03-21

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-05-19

E · Potential for more than minimal harm 2024-03-21

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-05-19

E · Potential for more than minimal harm 2024-03-21

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-05-19

C · Minimal harm 2024-03-21

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2024-05-15

E · Potential for more than minimal harm 2021-11-10

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-12-21

E · Potential for more than minimal harm 2021-11-10

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2021-12-21

E · Potential for more than minimal harm 2021-11-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2021-12-21

E · Potential for more than minimal harm 2021-11-10

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2021-12-21

D · Potential for more than minimal harm 2021-11-10

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-01-06

D · Potential for more than minimal harm 2021-11-10

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2021-12-21

D · Potential for more than minimal harm 2021-11-10

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2021-12-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-20

F678 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-19

F · Potential for more than minimal harm 2024-03-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-05

E · Potential for more than minimal harm 2024-03-21

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2024-04-05

C · Minimal harm 2024-03-21

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-04-05

E · Potential for more than minimal harm 2021-11-10

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-12-15

E · Potential for more than minimal harm 2021-11-10

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2021-12-15

E · Potential for more than minimal harm 2021-11-10

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2021-12-15

E · Potential for more than minimal harm 2021-11-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-12-15

E · Potential for more than minimal harm 2021-11-10

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2021-12-15

D · Potential for more than minimal harm 2021-11-10

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-12-15

D · Potential for more than minimal harm 2021-11-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2021-12-15

D · Potential for more than minimal harm 2021-11-10

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2021-12-15

D · Potential for more than minimal harm 2021-11-10

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2021-12-15

Penalties and ownership

What sits behind the stars

Ownership

Fgs. Inc.

5% Or Greater Indirect Ownership Interest · Organization

100% 1 facilities 2006-07-10

Allabaugh, Fredrick