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Deficiency Records for The Laurels of Goshen
A list of the most recent deficiencies for The Laurels of Goshen. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Laurels of Goshen. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-09 | 2024-08-30 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2024-08-09 | 2024-08-30 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-08-09 | 2024-08-30 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-11 | 2024-07-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-11 | 2024-07-29 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-06-21 | 2024-07-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-21 | 2024-07-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-21 | 2024-07-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-21 | 2024-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-21 | 2024-07-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-21 | 2024-07-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-21 | 2024-07-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-14 | 2024-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-14 | 2024-04-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-30 | 2023-12-28 | Y |
| Post nurse staffing information every day. | Health | 2023-11-30 | 2023-12-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-22 | 2023-10-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-07-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-06 | 2023-07-03 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-06 | 2023-07-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-06 | 2023-07-03 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-06 | 2023-07-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-06 | 2023-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-06 | 2023-07-03 | N |
| 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. | Health | 2023-06-06 | 2023-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-06 | 2023-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-06 | 2023-07-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-11 | 2022-04-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-11 | 2022-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-11 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-11 | 2022-04-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-11 | 2022-04-25 | N |
| 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. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-11 | 2022-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-25 | N |
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