Majestic Care of Goshen

In the surveyor’s words

From the most serious findings on record at Majestic Care of Goshen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 24, 2026

  Based on interview and record review, the facility failed to ensure post fall assessments and monitoring had been completed for 1 of 6 residents reviewed for falls. (Resident B) This deficient practice resulted in Resident B serious injuries due to having a delay in treatment related to a broken occipital bone and subarachnoid hemorrhages in April and a delay of treatment related to a broken humerus bone in June. In addition to the Immediate Jeopardy, the facility failed to ensure 2 of 6 residents reviewed for falls received thorough post fall assessments and monitoring which resulted in the potential for harm, that is not immediate jeopardy. […]

• Actual harm, isolatedF600Jun 2, 2026

  Based on interview, observation, and record review, the facility failed to ensure 2 of 3 residents reviewed for abuse were free from verbal abuse and physical injury when a Certified Nursing Assistant (CNA) was verbally abusive to one resident (Resident R), and physically abusive as evidenced by grabbed another resident's wrist during a transfer which resulted in bruising and skin tears to the resident's arm, (Resident P). Using the reasonable person concept, the abuse likely led to emotional distress related to intimidation and anxiety for both residents (Resident R and P) and actual physical injuries for Resident P.Findings include:On 5/29/26 at 3:00 P.M., an interview with the Administrator indicated he had been informed that earlier in the day, CNA 10 had been rough with a resident. […]

• Actual harm, isolatedF600Mar 2, 2024

  Based on observations, record reviews, and interviews, the facility failed to protect a resident's right to be free from verbal abuse from another resident, which resulted in emotional distress, and physical abuse by a staff member, for 3 of 4 residents reviewed for abuse. (Residents 68, 218 & 43) Findings include: 1. During a dining observation, on 2/25/2024 at 12:24 P.M., Residents 218 and 68 were sitting at the assisted dining table, and sitting side by side. Resident 218 was observed yelling at Resident 68. CNA 5 attempted to intervene verbally, but did not move Resident 218 from the table. Resident 218 continued yelling at Resident 68 to get up and walk so they could get out of here. […]

• Actual harm, isolatedF684Mar 2, 2024

  Based on interview, record review, and observation, the facility failed to identify and manage an acute change in condition of worsening respiratory symptoms, irregular blood sugar levels, and abnormal laboratory results not addressed. The deficient practice resulted in a delayed hospital evaluation, and hospitalization for pneumonia, acute kidney injury on chronic kidney disease, and cardiac disease (Resident 96). The facility failed to notify the physician of blood sugars outside of ordered parameters (Resident 109), to assess and treat a scabbed skin area (Resident 27), and to identify and notify the physician of bruising and swelling in a resident who received an anticoagulant medication (Resident 64) for 4 of 5 residents reviewed for quality of care. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF925Jul 24, 2026

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the physical environment remained free of vermin and pests and failed to promptly eradicate an ongoing insect infestation. This deficient practice affected the main kitchen and dry storage areas and had the potential to affect all 121 residents who resided in the facility and received food from the kitchen. See F0812 for additional information regarding storing and serving food in a safe and sanitary manner. Findings include:During an observation of the kitchen and dry storage areas on 7/19/2026 at 9:50 A.M., accompanied by the Assistant Dietary Manager 4, dead cockroaches were on the floor behind appliances, on shelves and on a windowsill. […]