Deficiency Records for The Laurels of Goshen
Updated as of June 01, 2020
This is not the most recent data for The Laurels of Goshen. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Develop a communication plan. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Establish methods for sharing information. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-01 | 2019-03-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-02-01 | 2019-03-03 | 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 | 2019-02-01 | 2019-03-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-01 | 2019-03-03 | 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 | 2019-02-01 | 2019-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-01 | 2019-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-01 | 2019-03-03 | 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 | 2019-02-01 | 2019-03-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-01 | 2019-03-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-01 | 2019-03-03 | 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 ne | Health | 2019-02-01 | 2019-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-01 | 2019-03-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-01 | 2019-03-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-20 | 2018-09-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-20 | 2018-09-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-20 | 2018-09-10 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Have an externally vented heating system. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-29 | 2018-04-11 | N |
