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Deficiency Records for Sapphire Nursing and Rehab at Goshen
A list of the most recent deficiencies for Sapphire Nursing and Rehab at 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 Sapphire Nursing and Rehab at 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? |
|---|---|---|---|---|
| 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 | 2023-02-07 | 2023-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-07 | 2023-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-04-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-07 | 2023-04-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-07 | 2023-03-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-12-24 | 2020-02-19 | N |
| Develop a communication plan. | Fire Safety | 2019-12-24 | 2020-02-19 | 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 | 2019-12-24 | 2020-02-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-24 | 2020-02-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-24 | 2020-02-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-12-24 | 2020-02-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-10 | 2020-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-10 | 2020-02-04 | 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 | 2019-12-10 | 2020-02-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-10 | 2020-02-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-10 | 2020-02-04 | 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 | 2019-12-10 | 2020-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-10 | 2020-02-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-10 | 2020-02-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-29 | 2018-04-09 | N |
| 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 | 2018-01-29 | 2018-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-29 | 2018-04-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-01-29 | 2018-04-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-29 | 2018-04-09 | 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 | 2018-01-29 | 2018-04-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-29 | 2018-04-09 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-01-29 | 2018-04-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-01-29 | 2018-04-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-29 | 2018-04-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-01-29 | 2018-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-29 | 2018-04-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-01-29 | 2018-04-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-01-29 | 2018-03-26 | N |
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