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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 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 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-25 | 2018-12-11 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-09-25 | 2018-12-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-09-25 | 2018-10-25 | N |
