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Deficiency Records for Goshen Healthcare Community
A list of the most recent deficiencies for Goshen Healthcare Community. 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 Goshen Healthcare Community. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-04-18 | 2024-05-17 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-04-18 | 2024-05-17 | 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 | 2024-04-18 | 2024-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-18 | 2024-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-18 | 2024-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-18 | 2024-05-17 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-17 | 2024-05-17 | 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 | 2024-04-17 | 2024-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| 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. | Health | 2024-01-23 | 2024-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-22 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-12-13 | 2024-01-18 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-20 | 2023-10-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-20 | 2023-10-18 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-26 | 2023-02-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-25 | 2023-02-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-01-25 | 2023-02-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-25 | 2023-02-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-25 | 2023-02-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-25 | 2023-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-25 | 2023-02-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-25 | 2023-01-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-02 | 2021-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2021-12-09 | N |
| Post nurse staffing information every day. | Health | 2021-11-04 | 2021-12-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-04 | 2021-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-09 | N |
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