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? |
|---|---|---|---|---|
| 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 | 2023-11-30 | 2023-12-28 | Y |
| Post nurse staffing information every day. | Health | 2023-11-30 | 2023-12-28 | Y |
| 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 | 2023-09-22 | 2023-10-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-07-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-06 | 2023-07-03 | 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 | 2023-06-06 | 2023-07-03 | 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 | 2023-06-06 | 2023-07-03 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-06 | 2023-07-03 | N |
| 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 | 2023-06-06 | 2023-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-06 | 2023-07-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-06 | 2023-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-06 | 2023-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-06 | 2023-07-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-12 | 2022-05-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-04-12 | 2022-05-15 | 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 | 2022-03-11 | 2022-04-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-11 | 2022-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-11 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-11 | 2022-04-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-03-11 | 2022-04-25 | N |
| 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 | 2022-03-11 | 2022-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-14 | 2021-06-08 | 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 | 2021-05-14 | 2021-06-08 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-04 | 2020-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-04 | 2020-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-04 | 2020-08-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-08-04 | 2020-08-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-08-04 | 2020-08-04 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-24 | 2020-03-30 | 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 | 2020-02-24 | 2020-03-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-24 | 2020-03-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-24 | 2020-03-30 | 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 | 2020-02-24 | 2020-03-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-24 | 2020-03-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-02-24 | 2020-03-30 | 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 | 2020-02-24 | 2020-03-30 | 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 | 2020-02-24 | 2020-03-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-24 | 2020-03-30 | N |
