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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-26 | 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-29 | 2021-08-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-29 | 2021-08-05 | Y |
| 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 | 2020-02-13 | 2020-03-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-13 | 2020-03-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-13 | 2020-03-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-02-13 | 2020-03-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-13 | 2020-03-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-02-13 | 2020-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-13 | 2020-03-17 | 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 | 2020-02-13 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-13 | 2020-03-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-11 | 2020-03-17 | 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 | 2020-02-11 | 2020-03-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-11 | 2020-03-17 | 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 | 2020-02-11 | 2020-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
