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Deficiency Records for Majestic Care of Goshen

A list of the most recent deficiencies for Majestic Care 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 Majestic Care 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?
Use approved construction type or materials. Fire Safety 2024-03-26 2024-04-28 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 2024-03-26 2024-04-28 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 2024-03-26 2024-04-28 N
Provide properly protected cooking facilities. Fire Safety 2024-03-26 2024-04-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-03-26 2024-04-28 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-03-26 2024-04-28 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-03-26 2024-04-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-03-26 2024-04-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-03-26 2024-04-28 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-02 2024-04-16 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-02 2024-03-22 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-03-02 2024-03-22 N
Respond appropriately to all alleged violations. Health 2024-03-02 2024-03-22 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2024-03-02 2024-03-22 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-03-02 2024-03-22 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2024-03-02 2024-03-22 N
Ensure each resident receives an accurate assessment. Health 2024-03-02 2024-03-22 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-03-02 2024-03-22 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 2024-03-02 2024-03-22 N
Provide activities to meet all resident's needs. Health 2024-03-02 2024-03-22 N
Assist a resident in gaining access to vision and hearing services. Health 2024-03-02 2024-03-22 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-02 2024-03-22 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 2024-03-02 2024-03-22 N
Provide enough food/fluids to maintain a resident's health. Health 2024-03-02 2024-03-22 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-03-02 2024-03-22 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-03-02 2024-03-22 N
Post nurse staffing information every day. Health 2024-03-02 2024-03-22 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-03-02 2024-03-22 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 2024-03-02 2024-03-22 N
Provide or obtain dental services for each resident. Health 2024-03-02 2024-03-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-02 2024-03-22 N
Provide and implement an infection prevention and control program. Health 2024-03-02 2024-03-22 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-03-02 2024-03-22 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-03-02 2024-03-22 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 2024-03-02 2024-03-22 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-03-02 2024-03-22 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-03-02 2024-03-22 Y
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 2024-03-02 2024-03-22 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-04 2024-01-12 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-10-23 2023-11-03 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-07-26 2023-08-11 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-07-26 2023-08-11 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-01 2023-06-15 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-05-01 2023-06-04 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-05-01 2023-06-04 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-01 2023-06-04 Y
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Health 2023-05-01 2023-06-04 Y
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 2023-05-01 2023-06-04 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-05-01 2023-06-04 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-05-01 2023-06-04 Y
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-02-01 2023-04-11 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-02-01 2023-03-25 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-02-01 2023-03-25 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-02-01 2023-03-25 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2023-02-01 2023-03-25 N
Establish policies and procedures for sheltering. Fire Safety 2023-02-01 2023-03-25 N
Establish policies and procedures for volunteers. Fire Safety 2023-02-01 2023-03-25 N
Establish roles under a Waiver declared by secretary. Fire Safety 2023-02-01 2023-03-25 N
Develop a communication plan. Fire Safety 2023-02-01 2023-03-25 N
Provide emergency officials' contact information. Fire Safety 2023-02-01 2023-03-25 N
Provide primary/alternate means for communication. Fire Safety 2023-02-01 2023-03-25 N
Establish methods for sharing information. Fire Safety 2023-02-01 2023-03-25 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2023-02-01 2023-03-25 N
Provide family notifications of emergency plan. Fire Safety 2023-02-01 2023-03-25 N
Establish emergency prep training and testing. Fire Safety 2023-02-01 2023-03-25 N
Establish staff and initial training requirements. Fire Safety 2023-02-01 2023-03-25 N
Conduct testing and exercise requirements. Fire Safety 2023-02-01 2023-03-25 N
Implement emergency and standby power systems. Fire Safety 2023-02-01 2023-03-25 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-02-01 2023-03-25 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 2023-02-01 2023-03-25 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2023-02-01 2023-03-25 N
Provide properly protected cooking facilities. Fire Safety 2023-02-01 2023-03-25 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-02-01 2023-03-25 N
Install an approved automatic sprinkler system. Fire Safety 2023-02-01 2023-03-25 N
Properly install and monitor supervisory attachments on automatic sprinkler systems. Fire Safety 2023-02-01 2023-03-25 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-01 2023-03-25 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-02-01 2023-03-25 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-02-01 2023-03-25 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-02-01 2023-03-25 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-02-01 2023-03-25 N
Provide a written emergency evacuation plan. Fire Safety 2023-02-01 2023-03-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-02-01 2023-03-25 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-02-01 2023-03-25 N
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Fire Safety 2023-02-01 2023-03-25 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-01-18 2023-02-10 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-01-18 2023-02-10 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 2023-01-18 2023-02-10 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-01-18 2023-02-10 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-01-18 2023-02-10 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-01-18 2023-02-10 N
Provide activities to meet all resident's needs. Health 2023-01-18 2023-02-10 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-18 2023-02-10 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2023-01-18 2023-02-10 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-01-18 2023-02-10 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 2023-01-18 2023-02-10 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 2023-01-18 2023-02-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-01-18 2023-02-10 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-01-18 2023-02-10 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-01-18 2023-02-10 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-01-18 2023-02-10 Y
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 2023-01-18 2023-02-10 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-01-18 2023-02-10 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-08-11 2022-08-31 Y
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 2022-08-11 2022-08-31 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-05-19 2022-06-07 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-03-25 2022-04-08 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-12-31 2020-02-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-12-31 2020-02-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-12-31 2020-02-03 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-12-31 2020-02-03 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2019-12-31 2020-02-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-12-31 2020-02-03 N
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Fire Safety 2019-12-31 2020-02-03 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2019-09-27 2019-10-27 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-09-27 2019-10-27 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 2019-09-27 2019-10-27 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 2019-09-27 2019-10-27 N
Provide and implement an infection prevention and control program. Health 2019-09-27 2019-10-27 N

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