Goshen Healthcare Community

In the surveyor’s words

From the most serious findings on record at Goshen Healthcare Community, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 26, 2023

  Based on observation, resident and staff interview. medical record review, and policy review, the facility failed to ensure residents received adequate supervision and assessment for 1 of 1 sample residents (#72) reviewed for accident hazards. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #72 had diagnoses which included acute embolism and thrombosis, cancer, deep vein thrombosis, arthritis, and non-Alzheimer's dementia. Further review showed the resident received an anticoagulant 6 of the 7 days during the look back period. Review of the care plan showed the resident had a risk of falls and required staff assistance of one for transfers to bed, mobility, and toileting. […]

• Actual harm, isolatedF564Jan 19, 2021

  Based on medical record review, resident representative interview, staff interview, and policy and procedure review, the facility failed to ensure residents received or were offered [MEDICATION NAME] care visits during a facility outbreak of COVID-19 for 3 of 11 sample residents (#66, #71, #72) reviewed with a change of condition. This failure resulted in harm to residents #71 and #72, who died without receiving a visit with family. The findings were: 1. Review of the medical record for resident #72 showed the resident had [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observation, staff interview, and 2022 U.S. Public Health Food Code review, the facility failed to ensure a sanitary equipment and failed to ensure food was stored under safe conditions in 1 of 2 food storage, preparation, and service areas (main kitchen). The census was 62. The findings were: 1. Observation on [DATE] at 2:14 PM showed the ice machine had a plastic piece which was not secured to the machine and a white powdery substance was built-up around the exterior above the door. Further observation showed the white powdery substance moved when the ice machine door was opened and closed and could fall into the ice. 2. […]

• No harm, potential for more than minimal, widespreadF801Nov 4, 2021

  Based on review of employee education, review of employee files, and staff interview the facility failed to ensure the director of the dietary department held certifications or education to meet the requirements. The census was 61. The findings were: Interview with the dietary director on 11/01/21 at 10:41 AM revealed in an attempt to meet qualifications she and the assistant manager had recently completed a ServeSafe food safety course. However, neither were certified as a foodservice manager or a dietary manager. Review of the employee file showed the dietary director had been in the director position starting in June 2018, and took a step down to work as a cook in November 2019. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2025

  Based on observation, resident and staff interview, and policy and procedure review, the facility failed to ensure personal protective equipment (PPE) was used for 2 of 9 sample residents (#8, #63) reviewed for infection prevention. In addition, the facility failed to report an outbreak of infectious disease involving 13 residents. The census was 74. The findings were: Regarding reporting facility outbreaks: 1. Observation on 7/21/25 at 2:40 PM showed the entrance doors had a sign that indicated the facility was experiencing an outbreak. Interview with the administrator at that time revealed the facility had several residents who were experiencing a respiratory illness. 2. […]